Please return confidentially via Post or Fax: Somerset Dementia Adviser Service

Alzheimer’s SocietyFirst Floor Office, Old Kelways

Somerton RoadLANGPORT

SomersetTA10 9SJ

Tel: 01458 251541Fax: 01458 251543

Referral criteria For people diagnosed with dementia, and/or their families and carers – The service provides signposting and information, as well as one-to-one support on the behavioural changes a person with dementia may experience offering information on a range of strategies and techniques.

N.B. People with Mild Cognitive Impairment cannot be supported via the Dementia Adviser Service. But please call 01458 251 541 for information and signposting.

Section 1 – Person with dementiaSurname of person with dementia: Title (Mr, Mrs, Miss, Ms, etc.):

Male Female

First name(s): Known as:

Date of birth:

Age:

Diagnosis:Does the person know the diagnosis? Yes No

Date given:

Given by:Address:

Postcode:

Home:Work:Mobile:

Email address:

Please specify if the person referred lives alone: Yes No

Maritalstatus: Single Married Civil Partnership Widowed Divorced Separated CohabitingConsent to contact the person with dementia? Yes NoSpecialist communication needs and preferred methods of communication e.g. Via telephone, contact carer, uses hearing aid, English not first language:

N.B. We will always contact the person with dementia in the first instance unless advised otherwiseIf you are making this referral on behalf of someone, please tick to confirm that they are aware of this referral and that they consent to the passing on of the details in this form.

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Please always complete this section Date:

From:

Relationship to person being referred: I.e. Husband/Wife, Consultant, GP, OT, Social Worker, CPN, etc.

Tel No:

Email:

If referral is being submitted by a statutory or voluntary organisation please record name, address and contact details:

Referral to Somerset Dementia Adviser Service

Private and confidential

Section 2 – CarerSurname: Title (Mr, Mrs, Miss, Ms, etc.):

First name(s): Known as:

Address: Same address: Yes No

Post code:

Date of Birth:

Male Female

Home:Work:Mobile:

Email:

Specialist communication needs and preferred methods of communication e.g. Hearing aids, English not first language:

Relationship to person with dementia:

Has the carer received a Carer’s Assessment?

Main carer? Yes No Key holder? Yes No Lasting Power Of Attorney? Yes No

Section 3 – Reason for referral for person with dementia and/or carere.g. Further information about diagnosis, benefits, the future, Alzheimer’s Society services, living well:

Any other relevant information including personal safety factors which we should be aware of before visiting for the first time:

How did you hear about our service? e.g. Service leaflet, poster, word of mouth, recommendation from a professional, etc.

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