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Thanks for your interest in our Creative Dementia programme.

If you require help in filling out this form please contact Salma on 07729 107 520 or email dementia@age-exchange.org.uk

Referral details

Who is making this referral

Full Name/Job Title

Referrer's Address

Referrer's Telephone Number

Referrer's Email

How did you hear about us?

Has the person given his/her consent to the referral being made?

Reason for referral to Age Exchange / what is the desired outcome of involvement in the project?

Does the person being referred have dementia?

If so, which type(s) of dementia?

If so, approximate date of diagnosis?

Identity

Forename

Surname

Also Known As

DateOfBirth

Getting around e.g. how will you get to the group, mobility aids you use etc

Do you have a Taxicard?

Dial-a ride?

Do you have go to any other services?

Other information that may be relevant, e.g. transport needs, dietary needs, medical needs, sensory needs (hearing aids, sight issues) likes, dislikes

GP Name and Address

Marital status

Media Consent

Upshot ID

Demographic

Gender

Ethnicity

Disability

Disability - please specify

Religion

Sexuality

Address

Address1

Address2

Town

County

Post Code

Ward

Contact

Telephone

Mobile

Main Carer Details

Name

Carers relationship to the person

Carers Address (if different from the person being referred)

Carers Emergency Contact Number

Carer's Email

Paid Carer Details (all correspondence will be through Main Carer)