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This free service offers your patients/clients the benefit of confidential support and information necessary to successfully navigate the challenges inherent with memory loss, Alzheimer's disease and other dementia.

Once received, the Alzheimer's Association will contact the referred individual within seven 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 send an action report back to you.

Complete the online form, save, and then print and fax to 410.561.3433 or email to For more information, contact our 24/7 Helpline at 800.272.3900. 

Download fax referral form HERE.