Name of Person Referred

Alzheimer Scotland

Referral & Service User Information for Dementia Day Service

URGENT REFERRAL ROUTINE REFERRAL
Name of Person Referred:
Preferred Name: / Referred by:
Date:
Address: / Ethnic Origin:
Communication issues (Hearing/Visually Impaired):
Tel No: / Lives alone: / YES NO
Email: / CHI Number:
Date of Birth: / Age: / NI Number:
Any Mobility/Transport Issues?: YESNO
Describe: / Is transport to Day Service needed?
Does the person have a carer?: YES NO
Please provide details of level of support provided both formally and informally?
General Health Information:
Diagnosis of Dementia: YES NO
Details: / On Medication: YES NO
Medication required during service: YES NO
Is person aware of Diagnosis?
Family aware of Diagnosis?
Is the person aware of Referral?
Is person known to Older Adults Psychiatry?
Post diagnostic support? / YES NO
YES NO
YES NO
YES NO
YES NO / Power of Attorney?
Guardianship?
Welfare and or financial? Please state:
Is person aware of charge for day service? / YES NO
YES NO UNKNOWN
YES NO UNKNOWN
Persons views on attending Day Service:
Carer’s perspective/views of current situation: / How stressful is situation at home for carer? Score 1-10 (10 being most stressful)
Health / Medical Information:
Any other medical conditions/allergies? i.e. does the person have diabetes/high blood pressure, allergies to food, medications etc:
Other relevant health issues:
About the person
Person’s interests? I.e. music/art/golf/football/animal lover?
Previous occupation(s):
Preference of who person likes to socialise with- men/women/neither?
Has the person tried any other Day Services? What/where?
What days are preferred, if any?
Are there any particular triggers of behavioural issues?
What calms the person?
What are the dietary requirements? Any support needed with eating? Does person prefer spoon to fork?
Does the person have toileting needs? How often/when/reminders/is help needed?

Any other relevant information? Any particular routines? Any issues around risk? Any issues re home environment?
Main contact: / Next of Kin: / Key Holder:
Address: / Address: / Address:
Tel No: / Tel No: / Tel No:
Email: / Email: / Email:
Relationship: / Relationship: / Relationship:
GP: / Social Worker:
Address: / Address:
Tel No: / Tel No:
Email: / Email:
CPN: / Community Care Co-ordinator
Address: / Address:
Tel No: / Tel No:
Email: / Email:
Advocate: / Interpreter:
Address: / Address:
Tel No: / Tel:
Email: / Email:
ELECTRONIC REFERRALS ARE PREFERRED.
PLEASE EMAIL COMPLETED REFERRAL FORM TO: