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Service Information
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Service Information

Service:

Health Care Professional Referral
Organization: Dementia Society of Ottawa and Renfrew County
Description:

A Dementia Care Coach provides expert support to improve the quality of life of caregivers, families and people living with dementia. We work with people and families impacted by dementia in all its forms. Dementia Care Coaches provide compassionate support, tailored coaching, and practical education for caregivers, families and people living with dementia.

Families do better with dementia when diagnosis and intervention is made as early as possible, and when they are well supported and connected in the community. We work with you and your family to: think about the future, manage dementia symptoms and live well, identify goals and priorities, access supports and services and listen compassionately.

Person Living with Dementia Information

Person Living with Dementia Name:

First name

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Family/Last Name

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Email Address:

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Phone:

Primary Phone

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Address:

Unit/Suite #

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Street # & Street Name

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City

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Province/State

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Country

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Postal/Zip Code

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Person Living with Dementia Health Card Number:

Person Living with Dementia Health Card Number

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Version Code

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Key Contact

Relationship to Person Living with Dementia:

Spouse

Son/Daughter

Parent

Friend

Other

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Key Contact Name:*

First name*

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Family/Last Name*

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Key Contact Email Address:

Email (Confirmation and reminder emails will be sent here)

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Key Contact Info:

Primary Phone*

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Unit/Suite #

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Street # & Street Name

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City

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Province/State

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Postal/Zip Code

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Health Care Professional

Health Care Professional Name:

First name

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Family/Last Name

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Health Care ProfessionalEmail Address:

Email (Confirmation and reminder emails will be sent here)

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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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Additional Information

Health Care Professional Details:*

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Consent

By clicking "Finish", you agree to send this personal information to Dementia Society of Ottawa and Renfrew County online.

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Summary

Reference #: -

Registrant:
Organization:

Dementia Society of Ottawa and Renfrew County

Service:

Health Care Professional Referral

Inquiry Phone:

1 (613) 523-4004

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