Date of Referral

Person with Dementia Full Name (probable or diagnosed):

Diagnosis & Date of Diagnosis (if known)

Date of Birth (mm/dd/yy)

Address

Telephone Number

Email Address

Can a voicemail message be left? Can a voicemail message be left? Yes No

Preferred Language of Choice for Service

Care Partner Full Name:

Relationship to above

Date of Birth (mm/dd/yy)

Address

Email Address

Telephone Number

Preferred Language of Choice for Service

Can a voicemail message be left? Can a voicemail message be left? Yes No

Referral Source Name & Agency:

Address

Phone Number

Fax Number

Email Address

I have received consent to refer: I have received consent to refer: Yes No

I am referring: I am referring: Person with Dementia Care Partner Both

Please Contact Please Contact Person with Dementia Care Partner Both

Please only include OHIP of referred persons:

Care Partner OHIP#:

Person with Dementia OHIP#:

Reason for Referral Reason for Referral Recently Diagnosed Living Arrangement/Transition Support Emotional Support Changes in Behaviour Information/Education Safety Concerns Finding Community Supports Staying Socially/Physically Engaged Other

Other/Specific Program, please specify

Additional Notes

Known Risks Known Risks Yes No

If yes, please select all that apply: If yes, please select all that apply: Family dynamics Infectious diseases Infestation/Squalor Pets Physical Environment Recent hospitalizations Responsive behaviours Smoking Weapons Other

Other known risks