Advance Dementia Support Team - Referral System
Important:
Please anonymise information wherever possible. Submitting referrals with personal identifiable information may result in the referral being declined.
Contact Details
Name
Email
Phone
Job Title
Address
Organisation Details
Organisation Name
Postcode
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Scenarios
Please select any scenario(s) that you are currently encoutering and specify a score from 1 (low) - 5 (high) to describe the likelyhood of the scenario occuring and how imminent it is.
Admission to hospital for physical health concerns
Likelihood
Please Select
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Imminence
Select Imminence
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Admission to hospital for other reasons
Likelihood
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Imminence
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Breakdown of current care home placement
Likelihood
Please Select
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Imminence
Select Imminence
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Carer breakdown resulting in move to alternative care setting
Likelihood
Please Select
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Imminence
Select Imminence
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Move to an alternative care home
Likelihood
Please Select
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Imminence
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Safeguarding
Likelihood
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Imminence
Select Imminence
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Other
Likelihood
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Imminence
Select Imminence
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Issues
Please identify any issues relation to you current referral
Advance care planning/personalised care planning
Behaviour and psychological symptoms
Communication and interactions
Meaningful engagement activities
Mental Capacity Act/Ethical advice
Other
Symptom management
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Referral Details
Please enter any other information relevant to the referral
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Submit Referral