Professionals referral form

Please fill in the form below to refer someone to our Dementia Adviser service.

The relevant dementia adviser for their part of Wiltshire will visit at home, get to know the person and any unpaid carers and family, assess their needs and help them to find the services and support they need.

They will then check in every six months to ensure ongoing support as the dementia progresses, or circumstances change.

Your information
About the person being referred
DD/MM/YYYY
Do they care for other people?
Do they live alone?
Diagnosis
Does the person know their diagnosis?
Does the person accept their diagnosis?