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 7-10 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
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
