Department on Aging
 

Dementia Referral Form

It's important that everyone take steps to reduce the spread of Coronavirus Disease 2019 (COVID-19). Find out more about COVID-19 and our ongoing response.

Updates in Response to Coronavirus (COVID-19)

Complete details on MCDA services that will be changing at this time as a precaution. 

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

This site is powered by the Northwoods Titan Content Management System

Menu

X