DA Referral form March 2017 .pdf

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Original filename: DA Referral form March 2017.pdf
Title: Alzheimer's Society Report Template
Author: Alzheimer's Society

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County Durham Dementia Advisor Service
Confidential Referral Form
Alzheimer’s Society
South Approach
Bullion Lane
Chester le Street
Co Durham DH2 2DW
Tel: 0191 389 0400, Fax No: 0191 388 5905

Referrer Details (or use practice stamp):
Name:
Organisation and address:

Job title:

Postcode:

Tel:

Details of the person being referred:
Full name:
☐Male ☐Female ☐Transgender
Address:

Title:
Date of birth:

Postcode:
Is the person aware of the referral?
Diagnosis of dementia?

Tel. No:



Type:

Date of Diagnosis:

Yes
Yes

Known as:




No
No

Details of Main Carer / Contact:
Full Name:
Address:

Postcode:
D.O.B

Title:

Relationship:

Tel. No:
Any other relevant info.

Further Details:
Has the person given consent for referral?
☐Yes ☐ No
Other Health Issues, e.g. Stroke, Parkinson’s Disease?
Any known communication issues?
Any known risks?
Reason for Referral:

Signed:

Date:

1
Please return to the Alzheimer’s Society, South Approach, Bullion Lane, Chester le Street, Co. Durham DH2 2DW,
Fax: 0191 3885905 or Email: durhamandchester@alzheimers.org.uk. Please insert the phrase alzecureemail! into
the title or body of your email to ensure it is delivered by secure email.
(Referral Form Version 7, March 2017)


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