Share or Print this page

Direct Connect
Rapid Referral

Click here for the online referral form. 
Find the fax version of the form here

Direct Connect Rapid Referral is a secure and HIPAA-compliant online form that directly links individuals and families to the Alzheimer’s Association for education, caregiver support and customized action plans.
This free service offers your patients the benefit of confidential support and information necessary to successfully navigate the challenges inherent with memory loss, Alzheimer’s disease and other dementias.

Once received, the Alzheimer's Association will contact the referred individual within two business days and assist with immediate needs. The Association will continue to serve the client with future needs as they arise. If the client gives permission, we will keep you in the loop and fax an action report to you.

Click here for the online referral form.

Find the fax version of the form here.

For more information, contact our 24/7 Helpline at 800.272.3900 or