PACIFIC DEMENTIA MĀNGALO REFERRAL (Online Form)

To refer someone with dementia to PACIFIC DEMENTIA MĀNGALO
You can fill out the online form and submit it electronically – or you can use the downloadable PDF PACIFIC DEMENTIAL MĀNGALO REFERRAL FORM Please print it off, fill it in and email it to us.

Email: dementia@athwa.org.nz
Postal Address: Aotearoa Tongan Health Workers Association INC. – ‘Ākiheuho | 25 Princes Street, Otahuhu | PO Box 22336, Otahuhu, Auckland1640, New Zealand

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Name *

First

Last

Designation

Date (Today)

Phone (Home / Work / Mobile)

Email *

Organisation

• Memory Clinic
• NASC
• GP
• SPECIALIST
• GERIATRIC SERVICES
• MHSOP
• AUCKLAND DISTRICT HEALTH BOARD
• WAITEMATA DISTRICT HEALTH BOARD
• COUNTIES MANUKAU DISTRICT HEALTH BOARD
• OTHER (Please specify on next textbox)

OTHER ORGANISATION (Please specify)

REASON FOR REFERRAL (Please select option/s)

• INFORMATION ON DEMENTIA
• PHONE CONSULTATIONS
• KEYWORKER SUPPORT / NAVIGATION
• SUPPORT GROUPS FOR CARERS
• EDUCATION COURSES FOR CARERS / FAMILIES
• ACTIVITY GROUPS FOR PERSON WITH MILD TO MODERATE DEMENTIA
• OTHER (Please specify on next textbox)

OTHER REASON (Please specify)

PERSON LIVING WITH DEMENTIA *

First

Last

PREFERRED NAME (Person living with dementia)

DATE OF BIRTH (Person living with dementia)

ADDRESS & POST CODE

Address of person living with dementia

PHONE (Home / Work / Mobile)

GENDER

• Male
• Female

ETHNICITY

NHI NUMBER

DIAGNOSIS (Type of dementia)

RECENT COGNITIVE TEST RESULTS

Please enter the Date/ Test/ Score/ Other: Specify

CARE DETAILS (We provide support services to carers) *

First

Last

ETHNICITY

DATE OF BIRTH

ADDRESS & POST CODE

RELATIONSHIP TO PERSON WITH DEMENTIA

EMAIL

PHONE (Home / Work / Mobile)

OTHER RELEVANT INFORMATION

CONSENT GIVEN

• Yes
• No

Submit