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Refer Yourself

Referral Form

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?

Diagnosis Information

(mm/dd/yy)
Invalid date.
(mm/dd/yy)
Invalid date.
Provide details about diagnosis
Diagnosis details are required.

Personal Information

(First name, Last name)
Full name is required.
(mm/dd/yy)
Invalid date.
XXXX-XXX-XXX-AA
Invalid OHIP number.
Address is required.
Invalid postal code.
(xxx) xxx-xxxx
Invalid phone number.
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.


Reason for Referral

Please select referral reason(s).
Please specify reason.

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