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Creative Dementia Referral Form

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

Date of Birth

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

Address

Address1

Address2

Town

County

Post Code

Borough

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

Name

Paid Carer's Telephone Number

Paid Carer's Email

Emergency contact

Telephone

Mobile

Main family carer details

Name

Carerâ€™s relationship to the person

Carerâ€™s Address (if different from the person being referred)

Carer's Emergency Contact Number

Carer's Email

Name of emergency contact