Direct Connect Rapid Referral

Name of person being referred

City

State

Zip code

Name of person being contacted
(if not the person being referred)

Relationship to person being referred

Self Spouse/Partner Son/Daughter Other

Mailing address

City

State

Zip code

Phone (cell)

Phone (home)

E-mail

Preferred contact method

Cell Phone Home Phone Email

Primary language

Preferred day/time to contact

Does the person being referred live with their primary caregiver? Yes No Self

May we identify ourselves as the Alzheimer's Association when we call? Yes No

May we leave a voicemail message? Yes No

May we email information? Yes No

May we postal mail information? Yes No

I give permission to my healthcare or service provider to fax or e-mail my name and contact information to the Alzheimer's Association. I understand that an Alzheimer's Association Helpline representative will contact me about support and educational opportunities. In addition to giving my permission to be contacted by the Alzheimer's Association, I give permission for the Alzheimer's Association to share a summary of our discussion with the referring provider as indicated above. I understand this is a free service provided by the Alzheimer's Association. I understand that my name, contact information or health information listed below will not be disclosed or shared with any other entity unless authorization is obtained by me.

Click (+) sign to expand signature box and type your name rather than sign

( + ) show alternative signature box

Signature:

Clear area

Date:

The person being referred provided verbal consent instead of their signature: Yes

To be completed by the professional

Professional's Name

Provider Organization/Department

City

State

Zip code

Phone

Fax

Reason for Referral

Education: Information on the disease, stages, symptoms, person-centered caregiving strategies

Services: 24/7 Helpline, support groups, education programs, resources in your community

Care Planning: Care options, staying in-home, managing activities of daily living, long term care placement, managing caregiver stress, safety

Provider's Comments

24/7 Helpline 800-272-3900 / www.alz.org FAX: 314-269-1624

I accept the legal terms and conditions

Direct Connect Rapid Referral Form - Greater Missouri