Page 131 - Dementia-Care-Specialist-Toolkit

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ALZ DIRECT CONNECT REFERRAL FORM

Fax or email this form to Alzheimer’s Los Angeles
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Fax # 323.686.5106 Email alzdirectconnect@alzla.org Date ________________ _
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F Check if primary contact F Check if primary contactct
PATIENT/CLIENT NAME FAMILY CAREGIVER NAME (if available)
______________________________________________ ______________________________________________
Address_______________________________________ Address_______________________________________
City_____________________________Zip __________ City_____________________________ Zip _________
Phone#_______________________________________ Phone#_______________________________________
Email ________________________________________ Email ________________________________________
Primary Language: Ƒ English Ƒ Spanish ප Other (specify) Relationship to Patient/Client:
_______________________________________________________________ ප Spouse/Partner ප Child ප Professional Caregiver
ප Other (specify) ________________________________
Is the patient/client on Medi-Cal AND Medicare?
Ƒ Yes Ƒ No Primary Language: Ƒ English Ƒ Spanish
ප Other (specify)________________________________
I give permission to the referring provider to forward my contact and paƟent informaƟon to Alzheimer’s Los Angeles.
I understand that a representaƟve will contact me and/or my caregiver about support, programs, and other services and will follow up
with the referring provider. Referrals will be entered into our secure database, unless indicated otherwise by checking this box ප.
Signature ____________________________________________________ Date_________________________
(PaƟĞnt/Client or Personal RepresentaƟve/Family Caregiver)
The person being referred provided verbal consent instead of signature ප Yes

REASON FOR REFERRAL (check all that apply)
ප Social Work ConsultaƟon & Support ප Research & Clinical Trials InformaƟon
ප Early Stage Services ප Legal & Financial ConsideraƟons
ප Support Groups ප Healthcare DirecƟves
ප AcƟvity Programs ප Respite Services
ප Safety Issues ප Caregiver EducaƟon
ප Home Safety ප Other (specify)____________________________
ප Driving
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ප Wandering (MedicAlert )
AddiƟonal InformaƟon: __________________________________________________________________________________________________________

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REQUIRED INFORMATION
Referring Provider Name ____________________________________ Title _________________________________
Provider Organization _______________________________________

Phone # ____________________ Fax #_____________________ Email____________________________________
How would you prefer to receive follow-up? ප Fax ප Email ප Follow-up unnecessary

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