Firstly, we want to thank our patients for their understanding and support as we have worked through our ongoing IT incident. Our staff have worked hard to maintain our services, and to provide care to our communities. We appreciate that the IT outage has resulted in delays and some disruption over the past week, and want to thank everyone involved.

Our focus has understandably been on continued safe and effective care, while NHS England oversaw a thorough and in-depth specialist investigation. This investigation has taken some time but we're pleased that following deep-dive research, there has been no evidence of unauthorised access to patient data.

As a result, we are now gradually and carefully reconnecting some of our priority patient systems, meaning that you should begin to see things return to normal. This will not be immediate and will not apply to all systems at present, so please bear with us as we adjust and reset.

For now, this continues to mean:

• If you are coming to us for a blood test, please make sure you have a paper form. If you do not have a paper form, we cannot do your blood test.
• Unless you are told otherwise, booked appointments are still going ahead as planned.
• If you are due a booked home visit and this has not happened, please call us on 0300 123 3444.

Our staff are working hard to get us back to normal safely and efficiently. Please bear with us, and be kind.

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Dementia Crisis Support Referral form

Dementia crisis support service

To find out how we use this information, our security and your rights visit our privacy page.

You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

Referrer details

Surname: *Required

Forename: *Required

Address: *Required

Telephone: *Required

Alternative contact number:

Patient details

Patient surname: *Required

Patient forename: *Required

Patient date of birth: *Required

Date / Date of birth

Patient NHS number: (if known)

Patient address: *Required

Patient telephone: *Required

Patient alternative contact number:

GP details: *Required

Has this patient been referred to this service before?

Yes

Next of Kin details

Next of Kin surname:

Next of Kin forename:

Next of Kin address: (if not as above)

Next of Kin telephone:

Next of Kin alternative contact number:

Is the next of kin the main carer? *Required

Is the next of kin the main carer?

Yes

If no, please provide carers name and contact number:

Is there another person / member of the family / carer who needs to be present for assessments and visits? If so please give name and contact details:

Reason for referral

Has the patient or the carer consented to the referral being made? *Required

Has the patient or the carer consented to the referral being made?

Yes

If no, please specify below:

Has this person been diagnosed with dementia? *Required

Has this person been diagnosed with dementia?

Yes

In process

Type of dementia (if known): (eg Alzheimers, vascular, etc)

Reason for referral: *Required

Reason for referral:

Physical Problem affecting dementia that could be managed at home

Challenging behaviour

To prevent unnecessary admission and/or to support early discharge

Carer stress or breakdown

Person at risk

Issues of safety awareness: (i.e. dog)

Other professionals involved in care package: (Name and role)

Brief description of problem: *Required

Email address: *Required

I agree to the privacy policy.

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Your experience is important to us and helps us to make sure our services provide excellent care. If you have any comments or queries about our services please see our contact us section.