Secure online referral

Refer to our service

Complete the secure online form, ask a GP, memory service, voluntary organisation or social prescribing team to refer, request a paper form by telephone, or visit our office for help completing one.

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Person being referred

Surname Forenames Date of birth Gender / how the person describes themselvesAddress Postcode TelephoneMobileEmailFirst languageReligion or beliefDietary needsAllergies

Carer and emergency contacts

Carer’s name RelationshipCarer’s mobileCarer’s home numberCarer’s addressCarer’s postcodeSecond emergency contact name and number

Health, home and support

Past and present medical history Year of dementia diagnosisCurrent medication Are parking facilities available?Who lives in the home?Pets—please give detailsConcerns we should know aboutPhysical health and mobility Details of family supportOther funded services in RedbridgeGroups attendedLikes and interestsDislikesWays RRCA may be able to provide support Known risks and how they are managed

Referral details

Referred by OrganisationReferrer telephone Referrer email Service required *

Email confirmation required

After submitting, please check your inbox and spam or junk folder. Open our email and select Confirm and send. Your form will not be sent to the RRCA team until you confirm it.

Human check: What is 4 + 5? *

Speak to our team

Refer to our service

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