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Dementia Referral Form

Dementia Care Specialist Referral Form

If an individual or a caregiver expresses concern about memory loss, dementia or Alzheimer’s, complete this referral form to connect them to our services. Upon receiving this referral, a dementia care specialist from Milwaukee County will contact them. 

The Dementia Care Specialists (DCS) with the Aging and Disability Resource Center of Milwaukee County focus on supporting people with dementia and their caregivers/families to ensure the highest quality of life possible while living at home. Dementia Care Specialists work with people and family members on a voluntary basis.

Please do not fill out a Dementia Care Specialist referral form if:

  • You need crisis services
    • If this is a medical emergency, please call 911.
    • If you are contacting to report or provide an update on a matter of abuse, neglect or financial exploitation or guardianship please submit a referral online.
  • The person with dementia lives in a care facility like an assisted living or nursing home
    • Connect with the dementia lead or nursing lead at the facility.
  • The person with dementia is enrolled in a Long Term Care Program (Family Care, IRIS, PACE, Partnership)
    • Connect with the dementia lead in their Long Term Care Program.

 

*Customer Name:
*Date of Birth:
*Street Address:
*City:
 
*State:
*Zip:
 
*Caregiver Name:
*Phone:
Email:

 

*What type of assistance do you need? Select all that apply.
 
Referral Source
If this is a referral, please provide your contact information for any follow-up questions.
*Referral Source Name:
Referral Source Email:

*Referral Source Phone:

 

Is there anything else you'd like us to know?

 

MILWAUKEE COUNTY DEPARTMENT OF HEALTH & HUMAN SERVICES

1220 W. Vliet St.

Suite 301

Milwaukee, Wisconsin 53205

Access DHHS 

How We Help

Our Vision

Together, creating healthy communities.

Our Mission

Empowering safe, healthy, meaningful lives.

Our Values

Partnership, Respect, Integrity, 

Diversity, Excellence

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