Admiral Nursing Referral Form

Admiral Nurse Referral Form

The criteria below must ALWAYS be met:

The family/carer must be providing care and support for a person living with a formal diagnosis of Dementia, recorded on EMIS/Clinical Web Portal (or other GP system).
Both family/ carer and person living with Dementia must live in one of the Black Country Boroughs (i.e. Wolverhampton, Sandwell, Walsall & Dudley) and/or have a registered GP within one of the Black Country Boroughs.
The family/carer needs cannot be met by other Dementia Partner services (i.e. Dementia Navigators, Carers Support and Education programmes)

One of the following criteria must also be met:

The family/carer are struggling to cope with managing risks & challenging needs, or the presentation of the person with Dementia.
The family/carer feel unable to cope with caring due to feeling of loss, guilt, stress and/or depression.
The family/carer are neglecting their own physical/ mental health needs due to their caring role.
The family/carer need support with psychological interventions to help them adjust and develop skills to support complex needs/behavior’s, particularly around periods of transition.
Conflict has arisen, which is affecting the family/carer ability to meet the person’s needs.
The family/carer require support recognizing/ adjusting/ coping with End of life. The carer needs advice around Advance Care Planning and future planning.

Any armed forces history or are a beneficiary to be referred to Royal British Legion Admiral Nurses

Referee Details

Please note: Referrals that aren’t completed fully will not be considered by the service. Self-referrals will also not be considered.

Name: Required

Job Title: Required

Address: Required

*Please enter a full, valid address in this field.

E-mail address: Required

Telephone Number: Required

Please select your locality. Required

Are you a professional/qualified health worker?

I confirm by checking, that I am a recognised health professional.

Has the patient served (or is a beneficiary) in the Armed Forces, National Guard etc.? Required

Confirm carer has consented to the referral being made and aware will be discussed with other Dementia Partners: Required

By clicking this, I acknowledge that the carer has consented.

Carer's Details

Name: Required

Address: Required

*Please enter a full, valid address in this field.

Date of Birth: Required

What is your ethnicity? Required

GP Surgery Required

*Please enter a full, valid address in this field.

Carer's Telephone Number: Required

Is an interpreter required? Required

Sensory Need details: Required

Relationship to person with dementia: Required

Please give any identified risks concerning carer and/or person with dementia: Required

Is there any reason that lone working visits should not be undertaken? Required

Reason for Referral/Summary of needs: Required

Other agencies involved:

If no agencies are involved, please state why? Required

Person living with Dementia details

Name: Required

Address: Required

*Please enter a full, valid address in this field.

What is the person's ethnicity? Required

GP Surgery Required

*Please enter a full, valid address in this field.

What is the person's Date of Birth? Required

Is the person living with Dementia aware of diagnosis?: Required

Type of Diagnosis and Date given: Required

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Admiral Nursing Referral Form

Referee Details

Carer's Details

Person living with Dementia details

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