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Dementia Friendly Fort Worth

"Be a Dementia Friend"

Agency Referral Form – GrandPad ®

Referral Date *

Please complete the form below and one of our staff will follow up with the client.

Referring Agency or Individual *

City *

Agency/Individual Contact Name *

First

Last

Agency/Individual Contact Phone Number *

Agency/Individual Contact Email *

Client's Name: *

First

Last

Client's Mailing Address *

Client's Email

Client's Phone Number *

Client's Gender *

Client's Race/Ethnicity *

Client's Date of Birth *

Reason for Referral (select all that apply) *

Anxiety
Boredom
Depression
Loneliness
Social Isolation
Lack of support system
SILOS Program
GrandPad Project

Client's Preferred Language

Does the client fit into any of the categories below? *

Minority
Lives in Rural area
Under-served (no internet connectivity, unable to access regular technology due to lack of resources, or unfamiliar with how to use technology, etc.)

Additional Information/Needs (challenges with fine motor skills, hearing loss, vision issues, or needs to be “drawn” to participate)

Client has received information verbal/written about the GrandPad Project and desires to participate. *

Yes
No

Client has consented to the agency referral in order to be evaluated for the GrandPad Project.

Yes
No

Receive an email copy of this form

Yes

Email address

This field is not part of the form submission.

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