GETTING LOST/WANDERING?

Please answer questions below to send the referral form to your local authority. The local authority will contact you within 2 to 5 days to make an appointment.

Do you live alone?
Yes No
Do you feel lonely?
Yes No
Does a friend or relative assist you with your care needs?
Yes No
Do you feel depressed for most of the day on most days?
Yes No
Do you forget things or have concerns about your memory?
Yes No
Do you get frustrated when you cannot do things you could once do?
Yes No
Do you sometime forget to take your medication or take a dose twice?
Yes No
Do you receive any homecare?
Yes No
Are you seeing an Occupational Therapist or Another Service?
Yes No
Are you concerned about any other risks?
Yes No