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Virtual Clinic
Common Behaviours
Open Access
Home
About
Virtual Clinic
Common Behaviours
Open Access
Test referral form
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Test referral form
Chat with a consultant
Person with dementia
First name
Last name
Sex
Female
Male
Intersex or indeterminate
Date of birth
Type of dementia
Alzheimer’s disease
Vascular dementia
Mixed dementia
Dementia with Lewy bodies
Frontotemporal dementia
Alcohol-related dementia
Other – please specify
No diagnosis (suspected dementia)
Other type of dementia -- please specify
If the person has suspected dementia, please comment here
What is the nature of the primary behaviour which prompted this referral?
Agitation
Aberrant Motor Behaviour
Anxiety
Apathy/Indifference
Appetite and Eating
Delusions
Depression/Dysphoria
Disinhibition
Elation/Euphoria
Hallucinations
Irritability/Lability
Night-time Behaviour
Physical Aggression
Physical Sexual Behaviour
Verbal Aggression
Other
Select an option to see description here
Please describe the nature of the behaviour selected above
Please describe your expectations of the outcome from this referral
Referrer
First name
Last name
Service name
Referrer service type
Carer (unpaid, family)
Care home
Domiciliary care
Housing support
Prison/Probation support
Other – please specify
Referrer service type -- please specify
Preferred contact number
Email address
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Privacy Notice
sets out how we protect, use and store your personal data. The personal details that you provide to us in connection with HammondCare Dementia Support will be used for the limited purpose of delivering this service in accordance with our Privacy Notice.
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Your referral with ID has now been sent and assigned the following ID: