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):*

Yes
Date of Referral:

MonthDayYear
Date
I am Referring:*

Person with DementiaCare PartnerBoth
Please Contact:

Person with DementiaCare PartnerBoth
Please provide the information on the next page according to who you have been provided consent to refer.

Person with Dementia Name (probable or diagnosed):*

First NameLast Name
Diagnosis Date and Diagnosis (if known):
Date of Birth:

MonthDayYear
Date
Person 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
Who should be contacted?*

Person with DementiaCare Partner
If the contact person is the care partner, please provide their name below:
Phone Number*
Please enter a valid phone number.
Can a voicemail message be left?*

YesNo
Email Address
example@example.com
Preferred Language of Choice for Service:

EnglishFrenchOther

Care Partner Name*

First NameLast Name
Relationship to above and/or Person Living with Dementia:
Date of Birth

MonthDayYear
Date
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.
Can a voicemail message be left?*

YesNo
Email Address
example@example.com
Preferred Language of Choice for Service:

EnglishFrenchOther