Alzheimer Society Waterloo Wellington Referral Form

Alzheimer Society Waterloo Wellington Referral Form
I have received consent to refer (please note we can only contact individuals for whom consent has been received):
Date of Referral:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I am Referring:
Please Contact:
Please provide the information on the next page according to who you have been provided consent to refer.

Person Living with Dementia or MCI Name (probable or diagnosed):

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Diagnosis Date and Diagnosis (if known):
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Person Living with Dementia OHIP # (Note - required by the Ministry of Health which funds our Programs & Services. If they do not have a Health Card, please note that in the box as we can still provide them with support.):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Ontario Health at Home involved in care plan?
Preferred Language of Choice for Service:

Other

Care Partner Name

First NameLast Name
Relationship to above and/or Person Living with Dementia:
Care Partner OHIP # (Note - this is required to set up a client file and please comment in box if you don't have access to it):
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Can a voicemail message be left?
Email Address
example@example.com
Preferred Language of Choice for Service:

Other
Would you like to refer a Secondary Care Partner?