Health Professional Referral Form

A referral to First Link® and our many programs and services will save you valuable time and energy.

It’s simple, just complete our online form OR fax us the completed Referral Form and our First Link® team will take care of the rest.

Your clients will receive:

  • Telephone contact offering an opportunity to meet with one of our Registered Social Workers for an in-home or in-office assessment to determine individual and family needs and work on an individualized plan of care.
  • An opportunity to participate in a variety of education and support groups, as well as social recreation programs (a client assessment is required prior) geared towards those in the early to mid stages of Alzheimer’s disease and other dementias.
  • Information about Alzheimer’s disease and other dementias.
  • Linkages to appropriate community services.

Prefer to Fax?

If you’d prefer to fax a referral form to Alzheimer Society Southwest Partners, please download our fillable form.

Complete Our Online Referral Form:

Can a voicemail message be left?

Can a voicemail message be left?

I have received consent to refer:

I am referring:

Please Contact

Reason for Referral

Known Risks

If yes, please select all that apply:

Quick Links to our available support programs and information:

Support for the Person with Dementia

Support for the Care Partner

Education for the Care Partner

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