Alzheimer Society Southwest Partners Online Referral

Alzheimer Society Referral Form

For people living with dementia, their care partners and professional referrals.
Please note there are mandatory fields in this form. You will need to complete all mandatory fields marked with an "*" before submitting the form. Once you have submitted the form, someone from our Intake team will reach out to the main contact indicated.
Today's Date*

MonthDayYear
Date
Is this a self or professional referral?*

For myselfOn behalf of my family/friend/person I supportProfessional referral (physican office, police, hospital, etc)
I consent or have received consent to refer? (Please note that all of our programs/services are voluntary. The individual you are completing this form for and/or being referred, must consent to receiving services from us.)*

YesNo
You have indicated that the individual has not provided consent to receive services from our organization. Please note that the person being referred must be informed and agree to you completing this form on their behalf, and they should be willing to engage in services. At this time, we are unable to proceed with the referral. If you have any questions or require further assistance, we encourage you to contact our office directly.

Middlesex-London office (519) 680-2404Elgin Office (519) 633-4396Oxford Office (519) 421-2466
I am referring:*

Person living with dementia onlyCare partner onlyBoth
Please select the area of residence for the Person living with dementia:*

London-MiddlesexElginOxford
Name of main contact (Person living with dementia, care partner etc that is to be contacted by our Intake team to book initial appointment)*

First NameLast Name
Main contact is:*

Person living with dementiaCare PartnerOther
Type of Care partner*

Spouse/partner of Person Living with DementiaChild of Person Living with DementiaFriend/Neighbour of Person Living with DementiaSibling of Person Living with DementiaOther
Date of Birth of Main contact*

MonthDayYear
Date
Phone Number of main contact*
Please enter a valid phone number.
Email of main contact
example@example.com
Preferred Language of Communication of main contact*

EnglishFrenchOther
Referral Source Name & Agency (please list your name and place of work)*
Referral Source Phone Number*
Please enter a valid phone number.
Referral Source Email
example@example.com
Please contact:*

Person Living with dementia onlyCare partner onlyBoth
Does this referral require urgent attention from our Behavioural support team?*

Yes, this referral should be directed to BSONo, this referral does not require urgent BSO attention
Please upload medical history and/or documents to support this referral if applicable

Cancelof
Cognitive Diagnosis of Person Living with Dementia*

Under InvestigationMild Cognitive ImpairementFrontotemporal DementiaAlzheimer's diseaseVascular DementiaLewy Body DementiaOther
Reason for Referral (please select all that apply) - Please note : We do not provide diagnostic services or support Long term care applications*

Recently diagnosedEmotional SupportLiving arrangement/Transition supportChanges in BehaviourInformation/EducationSafety ConcernsFinding Community SupportsStaying Socially and/or Physically engagedOther
Additional notes
Known Risks (please select all that apply)*

Family dynamicsRecent hospitalization(s)Infectious diseaseInfestation/squalorPetsPhysical EnvironmentSmokingWeaponsNo known risksOther
Should be Empty:

Alzheimer Society Referral Form

Please note there are mandatory fields in this form. You will need to complete all mandatory fields marked with an "*" before submitting the form. Once you have submitted the form, someone from our Intake team will reach out to the main contact indicated.