Department on Aging
 

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.

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

 

MILWAUKEE COUNTY DEPARTMENT ON AGING

1220 W. Vliet St., Suite 300
Milwaukee, WI 53205

Phone: (414) 289-6874
Toll Free:  1-866-229-9695
Fax: (414) 289-8568
TRS: 711
Email

Mission

Committed to the Independence and Dignity of Older Adults Through Advocacy, Leadership and Service

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