Self referral form

If you, or someone you care for, has a diagnosis of dementia, or is going through the process of being diagnosed, please fill in the form below to be referred to a dementia adviser.

The dementia adviser for your area of Wiltshire will then be in touch within 14 days.

If you are are a health or social care professional filling in the form on behalf of a patient or client, please use our professional referral form.

I'm referring for *
Your information
What is your relationship to the person you are referring
Please let us know what is concerning you. For example, memory difficulties, changed behaviours, difficulty moving around, etc
Does the person know that you are making this referral?
Who should be contacted about the referral?
Your information
DD/MM/YYYY
Do you have a diagnosis of dementia?
Do you live alone?
How would you like us to contact you?
About the person being referred
DD/MM/YYYY
Do they care for other people?
Do they live alone?
Please tell us about anything else that you think is relevant to this referral.