DCC Referral Form

Referral Form

This form is HIPAA compliant
Need to contact us? Call our referral line at 617-393-2130, send an email to directreferralmanh@alz.org, or send a secure fax to 617-321-4130.
Clinician has received verbal consent to refer Caregiver/Person Referred*

Yes
Caregiver Information
Caregiver/Person Referred*

First NameLast Name
Relationship to Person with Dementia*
Caregiver Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Caregiver Primary Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Caregiver E-mail
example@example.com
Preferred Contact Method
ex: phone
Caregiver's Primary Language
Caregiver's Race/Ethnicity
Patient Information
Patient Name
Patient Birth Date

MonthDayYear
Patient Age
Patient's Race/Ethnicity
Diagnosis
Diagnosis not required
Check here if patient lives with the person referred
Clinician Information
Referring Clinician Name *
Clinic/Practice*
E.g., Medical Center Name, Department
Clinician Phone Number*

Area CodePhone Number
Clinician FAX

Area CodePhone Number
Clinician Email*
example@example.com
How would you like to receive the summary?

EmailFAX
Areas of Concern
Key Concerns

Behavior management strategiesManagement of activities of daily livingCommunication techniquesCare options: adult day health/in-homeStaying home aloneFamily dynamicsMedicare/MedicaidDisease educationCaregiver stressDriving/transportation optionsLegal & financial/long-term care planningGeneral safety tipsTransitioning to long-term careEnd of life care/HospiceHousing options: Skilled nursing/ Assisted LivingOtherConsidering a Geriatric Care Manager for additional support
Other Concerns
Please check this box if the person with dementia would be upset if contacted by the Alzheimer’s Association. If checked, the Association will use caution when leaving voice messages and will use blank envelopes for information mailed to the caregiver.
By providing this information and clicking the "Submit" button, you acknowledge and consent to the terms of the Association's Privacy Policy.
Should be Empty:

Referral Form

Caregiver Information

Patient Information

Clinician Information

Areas of Concern