Kirklees Mental Health - Admiral Nurse Referral Form

Please consider the following when making a referral:

  • The person being cared for must have a diagnosis of Dementia (those with a learning disability or alcohol problem included)
  • The Carer is aware of the referral and agrees to it.
  • The Carer is experiencing difficulty in coping with aspects of their caring role.
  • Carers eligible to use the service will be over 18, registered with a Kirklees GP or resident in Kirklees and providing a caring role for the person with Dementia.
  • Anyone contacting the Kirklees Admiral Nurses not fitting this criterion will be signposted to Admiral Nurse Direct the national phone line, or another relevant local service.
  • Please complete this form in as much detail as you can to help enable us to understand the degree of need. We will aim ti allocate referrals within five working days. A waiting list may need to be instigated if necessary.

Please note carers should have agreed to this referral

Admiral Nurses Referral Form

Initial details
Carer details
Patient details
Overseas visitor?
Patient has consented to information sharing?*
Please provide an indication of what you hope to gain from your referral:
Referrer details