This form is for use by professionals only to refer people to Alzheimer’s Society dementia services. On receipt the person referred will be contacted to discuss their needs and how we can help them.
If you have not been issued with a Referrer ID, please enter your email address in the first field on the form to make a referral. If you have any issues with or questions about this form, please view our online referral guidance.
Please ensure you are using an up-to-date browser, such as Google Chrome, Microsoft Edge or Safari. If you do not have access to an up-to-date browser, please use the older version of the form.
If YOU are affected by dementia and need support for yourself or someone you know, you can use our Local service finder to search for support services near you. Alternatively call our Dementia Support Line on 033 150 3456