Dementia Referral Form

Centralize the clinical and contact information needed to refer a person with suspected or diagnosed dementia to specialized support and care services.

Use this template

Page 1

Who Is This Referral For?

The Person Themselves A Family Member A Healthcare Provider Other

Page 2

Name

Nombre

Apellido

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Address Line 2

Unit/Apt Number

City

Province

Postal Code

Date of Birth

Health Card Number

Phone Number

Can a Voicemail Message Be Left?

Yes No

Diagnosis

Diagnosis Date

Living Situation

Preferred Language of Choice for Service

English French Spanish Other

Family Doctor

Family Doctor Phone Number

Name

Nombre

Apellido

Address Same as the Person Living with Dementia?

Yes No

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Address Line 2

Unit/Apt Number

City

Province

Postal Code

Date of Birth

Health Card Number

Phone Number

Can a Voicemail Message Be Left?

Yes No

Alternate Phone

Relationship to the Person Living with Dementia

Is This Person the Power of Attorney (POA)?

Yes No

Preferred Language of Choice for Service

English French Spanish Other

I Have Received Consent to Refer

Yes No

Please Contact:

The Person with Dementia The Substitute Decision-Maker Both

Name

Nombre

Apellido

Agency/Organization

Discipline/Role

Phone Number

Reason for Referral

Caregiver Support Respite Care Case Management Long-Term Care Planning Community Resources

Is This Referral for One of the Following?

First Link Program Adult Day Program Support Group Education Session

Additional Notes

OHAH Community Care Coordinator

Nombre

Apellido

OHAH Community Care Coordinator Phone

OHAH Community Care Coordinator Email

Is the Referral on the Crisis Waitlist for Long-Term Care?

Yes No

Is the Contact Person for HISH the Same as Above?

Yes No

Contact Person

Nombre

Apellido

Contact Person Phone

Requested Hours of Respite per Day

Client Origin

Home Care Hospital Long-Term Care Home Community Referral

HCCSS Client Number

HCCSS Care Coordinator

Nombre

Apellido

HCCSS Care Coordinator Phone

HCCSS Care Coordinator Email

Is the Client Also Being Referred to the Alzheimer Society for Support? If Yes, Our First Link Coordinator Will Follow Up with the Contact Person/Care Partner

Yes No

Additional Notes (Brief Explanation of the Current Situation)

Known Risks?

Yes No

If Yes, Please Select All That Apply

Fall Risk Wandering Aggression Self-Neglect Medication Mismanagement Fire/Safety Hazard

Please Attach Supplemental Documentation as Appropriate

Max 10 MB per file

Dementia Referral Form

Page 1

Page 2

Related templates