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We can help you support those in your care. Speak to one of our experienced consultants
now on 1800 699 799 or fill out the form below and we’ll be in touch within 48 hours.

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our consultants

What is the nature of your referral to Dementia Support Australia?

By selecting this option you agree that this referral relates to a specific person with dementia who is experiencing changes in their behaviour that impact their care or the carer. This will lodge a referral of support through either the Dementia Behaviour Management Advisory Service (DBMAS) or Severe Behaviour Response Team (SBRT).

The SDCP provides specialist accommodation, management and support for those people living with dementia who are unable to be cared for by mainstream aged care services. For more immediate behaviour support, please select "Behaviour Support: Dementia Support Australia" to lodge a referral relating to a specific person.

Consent

This person (or next of kin/guardian) has given consent for this referral. Dementia Support Australia needs consent to ensure privacy of our clients.

YesNo

Person with Dementia's Details

First Name

Last name

Sex

Date of Birth

Where is the person currently staying?

Search for Organisation Name (or address)

Name of Facility

Street Address

Suburb

State

Postcode

From what date has the person been staying in their current accommodation? (Estimated)

Please enter a date in dd/mm/yyyy format

What is the person's usual living arrangement?

Has the person been diagnosed with dementia?

Dementia Type?

What is the behaviour which prompted this referral?

Please provide examples of the behaviour

Please Use English Language

Please describe your expectations of the outcome from this referral

Please Use English Language

In the last month, how often has this behaviour occurred?

What has been the impact from this behaviour?

How would you rate the level of risk with this behaviour?

Do you have strategies in place to manage the behaviours and reduce the risks?

Referrer's Details

First Name

Last Name

Relationship to person being referred

Are you the Next of Kin or Guardian of the person being referred?

YesNo

Preferred Contact Number

Please provide a valid Australian phone number

Email Address

Are you submitting this as an employee of an organisation?

YesNo, I am not referring as part of an organisation

Are you an employee of the organisation entered above?

YesNo, I am referring as a part of a different organisation.

Organisation Name

Street Address

Suburb

State

Post Code

Please upload any relevant documentation to support the referral (eg. Medicine/behaviour charts, relevant documentation from geriatric specialists, etc.)

Attachments

Refer someone today

We can help you support those in your care. Speak to one of our experienced consultants now on 1800 699 799 or fill out the form below and we’ll be in touch within 48 hours.

Contact one of our consultants

If your referral doesn’t relate to a client/resident, please use our enquiry form

We can help you support those in your care. Speak to one of our experienced consultants
now on 1800 699 799 or fill out the form below and we’ll be in touch within 48 hours.

Contact one of
our consultants