» Referral Form | Alzheimer Society Ontario

Information that you provide in this referral form will be sent by the Alzheimer Society of Ontario First Link Program to the local Alzheimer Society that can provide support to the person living with dementia and/or their caregiver. If information is missing (for example, postal code), the Alzheimer Society of Ontario First Link team may follow up to help make the connection to the applicable local Society.

Who is filling out the form?

Person Living with Dementia Caregiver Professional

Diagnosis Information

Date of Referral: *

(mm/dd/yy)

Invalid date.

Date of Diagnosis (if known):

(mm/dd/yy)

Invalid date.

Under Investigation

Specify here: *

Provide details about diagnosis

Diagnosis details are required.

Personal Information

Person Living with Dementia Name (probable or diagnosed): *

(First name, Last name)

Full name is required.

Date of Birth:

(mm/dd/yy)

Invalid date.

OHIP#:

XXXX-XXX-XXX-AA

Invalid OHIP number.

Address: *

Address is required.

Postal Code: *

Invalid postal code.

Telephone Number: *

(xxx) xxx-xxxx

Invalid phone number.

E-mail Address:

Invalid e-mail address.

Just like at a doctor’s office, as part of the health care system, the Alzheimer Society collects personal health information from you such as your date of birth and OHIP number to identify you and to provide you the best possible care.

Can a voicemail message be left:

Yes No

Preferred Language of Choice for Service:

English French Other

Care Partner Information

Care Partner Name: *

(First name, Last name)

Full name is required.

Date of Birth:

(mm/dd/yy)

Invalid date.

OHIP#:

XXXX-XXX-XXX-AA

Invalid OHIP number.

Address: *

Same as Person with Dementia

Other

If address is Other, please specify:

Please specify address.

Postal Code

Invalid postal code.

E-mail Address:

Invalid e-mail address.

Relationship to Person with Dementia: *

Please specify relationship.

Telephone Number: *

(xxx) xxx-xxxx

Invalid phone number.

Can a voicemail message be left:

Yes No

Preferred Language of Choice for Service:

English French Other

Referral Form

Who is filling out the form?

Who are you referring?

Who should we contact?

Diagnosis Information

Personal Information

Care Partner Information

Referral Information

Reason for Referral

Click here to find a First Link^® Program in your Community

Referral Form

Who is filling out the form?

Who are you referring?

Who should we contact?

Diagnosis Information

Personal Information

Care Partner Information

Referral Information

Reason for Referral

Click here to find a First Link® Program in your Community

Click here to find a First Link^® Program in your Community