Self-Referral Form

You can make a referral to us for yourself by downloading and completing this form

Emailing the completed Word referral form back to us at:

info@dementiayealm.org

Or by giving us a call on:

07450 206312

When we receive the referral, we will contact you and/or if appropriate, other people involved in the referral to gain a better understanding of you situation and needs and to see what support we may be able to provide.

or you can simply fill out the following online form, we will receive the information instantly, and we will contact you as soon as possible

YOUR DETAILS & CONTACT INFORMATION

All the information provided will remain strictly confidential within the charity.

Being part of the project has changed our lives.

Vivien Pink

As a carer it’s great to know I am not alone and that there is always someone I can call.

Vivien Pink

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