Self Referral Form
Are you or a loved one experiencing memory loss?
Do you want more information on Mild Cognitive Impairment or dementia?
We can help.
Call the office in your area or submit the form below.
Please note: Due to a significant increase in self-referrals, our estimated response time is currently up to 30 business days.
Elgin
450 Sunset Dr. Suite 229
St. Thomas, ON
N5R 5V1
519-633-4396
Middlesex
435 Windermere Rd.
London, ON
N5X 2T1
519-680-2404
Oxford
575 Peel St.
Woodstock, ON
N4S 1K6
519-421-2466
Connect with Us:
Self-referral Form
Pease fully complete this form. The information requested below is important in ensuring that we know what region the new client will be requiring services.
