Wakefield Admiral nurse referral form Wakefield Admiral Nurses Referral form If you are making a referral, fill in the details below. Please complete as much of the information as possible. 1234 X/TwitterThis field is for validation purposes and should be left unchanged. Referral criteria The carer must be over 18 and registered with a Wakefield GP. The carer must be providing care and support for a person with a formal diagnosis of dementia of any type. MCI / pre-diagnostic support is not provided. This is a Tier 3 service for carers with complex needs related to dementia, where those needs cannot be adequately met by other services. Important Admiral Nurses is not an emergency or crisis response service. They support family carers at all stages of the illness, including transitions through care. If you need urgent care please use the urgent help link above or call 999. Expected response times Routine referrals – response within 6 weeks following receipt of the referral by the Admiral Nurse. Urgent referrals – telephone contact within 5 working days following receipt of the referral by the Admiral Nurse. The service offers clinic appointments, home visits and telephone support based on need. Referrer detailsDate of referral(Required) Day Month Year Name of person making referral(Required) Prefix MrMrsMissMsDrProf.Rev.MxOther First Last Organisation(Required)Telephone numberEmail I feel this referral is:(Required) Routine Urgent Consent to make referral I confirm I have consent from the carer to make this referral Important We cannot accept referrals without carer consent. Main carer detailsName(Required) Prefix MrMrsMissMsDrProf.Rev.MxOther First Last Relationship to person with dementia(Required)Make selectionSpousePartnerParentNext of kinGuardianFoster parentPolygamous partnerDependantNon dependantOtherRelationship other(Required)Please state relationship to person with dementiaDate of birth(Required) Day Month Year NHS number (if known)GP surgeryAddress Street Address Address Line 2 Town County Post Code Phone number(Required)Add a second carer to this referral? Yes Second carer detailsSecond carer name(Required) Prefix MrMrsMissMsDrProf.Rev.MxOther First Last second carer relationship to person with dementia(Required)Make selectionSpousePartnerParentNext of kinGuardianFoster parentPolygamous partnerDependantNon dependantOthersecond carer relationship other(Required)Please state relationship to person with dementiaSecond carer date of birth(Required) Day Month Year Second carer NHS number (if known)Second carer GP surgerySecond carer address Street Address Address Line 2 Town County Post Code Second carer phone number(Required) Person with dementia detailsName(Required) Prefix MrMrsMissMsDrProf.Rev. First Last Date of birth(Required) Day Month Year NHS number (if known)Does this person live with the main carer Yes No Address (if different to main carer) Street Address Address Line 2 Town County Post Code Diagnosis detailsPlease enter details of of the persons diagnosisGP surgeryDiagnosed by:Diagnosis dateIf knownIs the person aware of their diagnosis Yes No Lacks insight Case informationReason for Referral(Required)Please explain why Admiral Nurse support is required. Include the nature and complexity of the carer’s needs, the impact on their wellbeing or caring role, and what their hopes are from referralRisks(Required)Please outline any identified risks relating to the carer or the person living with dementia, including safeguarding concerns and any issues relevant to lone working:Other informationPlease list any other services currently involved with the carer or person living with dementia, or any additional relevant information (e.g. sensory impairment, interpreter required, housebound):CAPTCHA Page last updated on: 21st May 2026