Who is this referral for
*
A person living with dementia
A caregiver/contact person
Both a person living with dementia & caregiver/contact person
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Person Living with Dementia (probable or diagnosed)
Name
First Name
Last Name
Address
Street Address
1
Street Address Line 2
City
Province
Postal Code
Date of Birth
-
Month
-
Day
Year
Date
Health Card Number
10 digit number plus 2 letter version code
Phone Number
-
Area Code
Phone Number
Can a voicemail message be left?
Yes
No
Email
example@example.com
Diagnosis
Alzheimer's Disease
Vascular Dementia
Lewy Body Dementia
Frontotemperal Dementia
Mixed Dementia
Unspecified Dementia
Huntington's Dementia
Parkinson's Dementia
Alcohol Related Dementia
Mild Cognitive Impairment
Normal Pressure Hydrocephalus
No formal diagnosis/Under investigation
Diagnosis Date
-
Month
-
Day
Year
Date
Living Situation
Alone
Spouse/Partner
Adult Children
Other
Preferred language of choice for service
English
French
Other
Family Doctor
Family Doctor Phone Number
-
Area Code
Phone Number
Care Partner/Contact Person Information
Name
First Name
Last Name
Address same as person living with dementia?
Yes
No
Address
Street Address
2
Street Address Line 2
City
Province
Postal Code
Date of Birth
-
Month
-
Day
Year
Date
Health Card Number
10 digit number plus 2 letter version code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Can a voicemail message be left?
Yes
No
Alternate Phone
-
Area Code
Phone Number
Relationship to person living with dementia
eg. Spouse, child, friend
Is this person the POA?
Yes
No
Preferred language of choice for service
English
French
Other
Referral Source
I have received consent to refer
*
Yes
No
Please contact:
*
Person living with dementia
Care Partner/Contact Person
Both
Name
*
First Name
Last Name
Agency/Org
*
Discipline/Role
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Reason for Referral
*
Recently Diagnosed
Emotional Support
Information/Education
Finding Community Supports
Living Arrangement / Transition Support
Changes in Behaviour
Safety Concerns
Staying Socially/Physically Engaged
Other
Additional Notes (brief explanation of the current situation)
Known risks?
*
Yes
No
If yes, please select all that apply
Family dynamics
Infectious diseases
Infestation/Squalor
Pets
Physical Environment
Recent hospitalizations
Responsive behaviours
Smoking
Weapons
Other
Please attach supplemental documentation as appropriate
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