Make a Referral

You can use the form below to contact us if you wish to refer someone living with dementia in the London Borough of Ealing, or who pays taxes to Ealing Council, to Dementia Concern to enable them to access our services. Please provide your own contact details below. Once you have submitted this form you will be contacted by a member of our team to complete the secure referral process.

Your details

Please complete below your own details or details of the person who is making the referral. We will use these details to get in contact and complete the referral process.

Details of the person being referred

Please provide us with the name of the person being referred. We need to know this to check if this is a new referral to us. We do not require any further personal details at this time, but they will be requested later in the referral process.

Our Services
Your Privacy

We will always store your personal details securely. We’ll use them to provide the service that you have requested, and communicate with you in the way(s) that you have agreed to. Your data may also be used for analysis purposes, to help us provide the best service possible.

Dementia Concern is contracted by Ealing Community Partners/West London NHS Trust, to deliver dementia services in Ealing. There are two data base systems in use. SystemOne is for contract reporting and Charity Log is the internal database for clients. The charity holds client data on both SystemOne and Charity Log. The purpose of the holding this data on both systems is to provide an adequate service to the clients. The legal basis for the charity holding this data is that of Data Controllers, as the charity provides direct care to patients, and therefore are able to determine the use and purpose of the data that is held. If a service user has any queries regarding the processing of their data they should contact [email protected] The retention period for this information is seven (7) years from when the client last uses the charity’s services. When obtaining consent from clients, the staff aim to highlight to the client that their data is held on two database systems, SystemOne and Charity Log.

Review our Privacy Policy at