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Younger People with Dementia Referral Form

Please select from the following before proceeding

Start new referral
Retrieve previous referral progress

Email Address

Reference Number

Verification Code (Please enter the code emailed to you)

Please complete this form, as fully as possible, with relevant information and details to support the referral.

Section 1 - Referrer's Information

*Legal First name

*Legal Last Name

*Role

Trust

*Department

*Email

*Address

*Contact Number

*Is this referral for yourself?

Section 2 - Key information about the Patient

*Legal First Name

*Legal Last Name

*Date of Birth

*NHS number

*Address

*Postcode

*Contact Number

*Gender

Marital Status

Ethnicity

Religion

*Registered GP practice

*Registered GP address

*Registered GP telephone number

*Is an interpreter required?

Interpreter language Type

Consultant Name

Consultant Address

Consultant Telephone Number

Section 3 - Reason(s) for referral

*Reason for Referral (please include full bloods/medical history/current medications and other relevant information. (Duration onset of symptoms, how this is affecting the individual, how is this impacting on their function) - previous brain scans and previous cognitive assessments/MMSE/6CIT. Any bloods out of range must be treated accordingly by GP if possible before referral sent, to include B12, thyroid, folate)

Section 4 - Consent

Consent must be sought to share personal information with Northamptonshire Healthcare NHS Foundation Trust and other organisations that can offer support relevant to this referral

*Tick this box to confirm that consent has been discussed and received with the client or patient

Section 5 - Referral Details

*Brief history of difficulties/area of risk/other important information (any relevant information for home visit, safety wise, past mental health history)

*Next of kin/carer

*Next of kin address

*Next of kin contact number

*Relationship to client

*Appropriate to contact

Other Agencies/Professionals involved

Name

Telephone number

Job Title/role

Attachments

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DATA PROTECTION NOTICE

Data that you provide to the Trust is processed in accordance with the Data Protection Act 2018, please see the Trust Privacy Notice for further information on how data is used:

https://www.nhft.nhs.uk/privacy/

NHFT Referral Forms