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
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- The field Name: is required.
- The field Job Title: is required.
- The field Address: is required.
- The field E-mail address: is required.
- The field Telephone Number: is required.
- The field Please select your locality. is required.
- The field Has the patient served (or is a beneficiary) in the Armed Forces, National Guard etc.? is required.
- The field Confirm carer has consented to the referral being made and aware will be discussed with other Dementia Partners: is required.
- The field Name: is required.
- The field Address: is required.
- The field Date of Birth: is required.
- The field What is your ethnicity? is required.
- The field GP Surgery is required.
- The field Carer's Telephone Number: is required.
- The field Is an interpreter required? is required.
- The field Sensory Need details: is required.
- The field Relationship to person with dementia: is required.
- The field Please give any identified risks concerning carer and/or person with dementia: is required.
- The field Is there any reason that lone working visits should not be undertaken? is required.
- The field Reason for Referral/Summary of needs: is required.
- The field If no agencies are involved, please state why? is required.
- The field Name: is required.
- The field Address: is required.
- The field What is the person's ethnicity? is required.
- The field GP Surgery is required.
- The field What is the person's Date of Birth? is required.
- The field Is the person living with Dementia aware of diagnosis?: is required.
- The field Type of Diagnosis and Date given: is required.
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