Dementia NI Referral Form

Dementia NI is a membership led organisation where all members have a diagnosis of dementia. Dementia NI membership is specifically for people living with dementia, we currently do not provide a service for families and carers.

Dementia NI Referral Criteria

Individuals require confirmation from the Memory/Care services or their GP/Consultant that the provision offered by Dementia NI would be suitable for their needs.

To get the most out of our organisation, an individual must be able to:

feel comfortable and able to participate.
communicate effectively and comfortably within a group setting.
manage personal and self-care needs independently.

Referral for Membership applies to:

Individuals in the earlier stages of dementia progression.
Individuals with any type of dementia.
Individuals with a diagnosis of dementia regardless of adult age.
Individuals who are aware of their diagnosis and willing to discuss what life is like living with dementia.

There are different options to become a member of Dementia NI. A Dementia NI Empowerment Facilitator will discuss these options during initial contact with the individual living with dementia.

Diagnosis

Does the individual have a confirmed diagnosis of dementia?

Is the individual aware of their diagnosis?

Referral Information

Dementia NI only accepts referrals for people with a confirmed diagnosis of dementia. The individual needs to be aware of their diagnosis in order to access our services.

If you wish to discuss the referral of someone awaiting probable diagnosis of dementia please contact us first on 028 96 931 555 to discuss.

Individual Being Referred

First Name	Last Name
Salutation	Other Salutation
Preferred Name	Marital Status
Date of Birth People must be over 18 in order to access Dementia NI services.	Gender
Email	Address
Daytime Telephone	Postcode
Mobile Telephone

Current Situation

Dementia type(s)?

To select multiple options hold down the control (Windows) or command (Mac) key.

Dementia type(s) details:

Who made the diagnosis?

When was it made?

What are the individual’s current main difficulties?

Does the individual have insight into their current difficulties?

Has the individual capacity to manage their own appointments?

Details of other health issues e.g. other medical conditions or disabilities:

Does the person live alone?

What type of accommodation?

If other, please provide details:

Preferred method of communication:

Other communication method:

Are there factors which need to be considered prior to Dementia NI visiting the individual at home:

Any further information that Dementia NI should be made of:

Additional Resources

Dementia NI offer an ‘In the Same Boat’ Support service whereby a person recently diagnosed can avail of peer support from an existing Dementia NI member who has a diagnosis of dementia.

Would the individual like to avail of ‘In the Same Boat’ Support?

The award-winning JAM Card (Just A Minute) allows people with dementia or other communication barriers to ask for just a minute of patience when they need it. The Dementia JAM Card is for people living with dementia / memory problems and is a discreet way of telling people that they may sometimes need a little extra time and patience.

Does the individual require a Dementia JAM Card?

Tablet Loan Scheme

The Tablet Loan Scheme is intended for people diagnosed with dementia who become Dementia NI Members and do not have access to a tablet, laptop or smartphone. The service enables those who would like to get involved in the virtual group meetings, stay in contact with other members, enjoy a range of online activities, and join in with the conversation on the Dementia NI private Facebook 'In the Same Boat' group. This is a loan service only.

Does the individual need to loan a Dementia NI tablet?

Emergency Contact Details

Nearest caring relative/carer

First Name	Last Name
Relationship to Individual	Email
Address	Postcode
Daytime Telephone	Mobile Telephone
Keyholder

Emergency Contact Details

Would you like to add a second emergency contact?

Second Emergency Contact

First Name	Last Name
Relationship to Individual	Email
Address	Postcode
Daytime Telephone	Mobile Telephone
Keyholder

GP/Consultant Details

You must provide contact details for either a GP or Consultant. Please select which.

GP Details

Name	Telephone
Address	Postcode

Consultant Details

Name	Telephone
Address	Postcode

Designated CPN/Care Manager/Social Worker Details

Name	Telephone
Address	Postcode

Referral Details

First Name

Last Name

Telephone

Email

Organisation Name

Job Title

If you are their Dementia Navigator, please indicate this here.

Team

Trust

Referral Criteria

To get the most out of our organisation, an individual must be able to:

feel comfortable and able to participate.
communicate effectively and comfortably within a group setting.
manage personal and self-care needs independently.

Referral for Membership applies to:

Individuals in the earlier stages of dementia progression.
Individuals with any type of dementia.
Individuals with a diagnosis of dementia regardless of adult age.
Individuals who are aware of their diagnosis and willing to discuss what life is like living with dementia.

I can confirm that I have read the referral criteria and confirm that the person I am referring has a diagnosis of dementia. I have obtained consent for the information gathered to be passed to Dementia NI and kept on record in accordance with GDPR.

I confirm the above statement