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Service Information
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Service Information

Service:

Covid-19 Dementia Support
Organization: Dementia Society of Ottawa and Renfrew County

Caregiver Information

Caregiver Name:

First name*

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Family/Last Name*

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Email Address:

Email (Confirmation and reminder emails will be sent here)

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Phone:

Primary Phone

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Address:

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Street # & Street Name

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Contact Time:

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7 - 8 AM

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12 - 2 PM

2 - 4:30 PM

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Conduct Appointment With:

Caregiver

Person Living with Dementia

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Person Living with Dementia

Relationship to Caregiver:

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Person Living with Dementia Name:

First name

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Family/Last Name

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Health Information

Referral Urgency:

Routine/Elective

Urgent

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Reason for Referral:

e.g., New Diagnosis, Recent hospital admission, Caregiver burnout, etc..

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Risk Factors:

Behavioural Changes

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Caregiver Stress / Emotional Support

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Driving Concerns

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Financial Concerns

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Housing Concerns

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Nutrition Concerns

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Recent Diagnosis

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Safety Concerns (wandering, hoarding, cooking)

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Other

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Consent

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Summary

Reference #: -

Registrant:
Organization:

Dementia Society of Ottawa and Renfrew County

Service:

Covid-19 Dementia Support

Inquiry Phone:

1 (613) 523-4004

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