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CogCoach-Brain GP with patient form

Current Section 1: For Clinician to Complete
Section 2: For Patient to Complete
Complete

Would you like to refer a patient to CogCoach-Brain?

If you would like to refer a patient to CogCoach-Brain as part of your involvement in Healthed’s continued professional development. Please use the form below. This should be filled out together with the patient.

Section 1: For Clinician to Complete

Declaration by referring Clinician

I have read the patient the information statement or covered the key points provided by the CogCoach-Brain team.

Referral checklist

Patient is aged 60 years or older

Yes

No

Patient can read, write and communicate in English to a comfortable level?

Yes

No

Patient is willing to complete an online course and interviews via phone/video call?

Yes

No

Patient has access to a computer, tablet or smartphone and the ability to connect to the internet?

Yes

No

Patient is willing to nominate a friend, family or carer to provide information about their memory, and thinking, and everyday behaviour at the beginning and the end of the study?

Yes

No

Details of participant

Participant’s name

Participant’s name

Participant’s phone number

Participant’s email address

Details of referring GP

GP name

GP name

GP clinic name/address

Address

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Address 2

City/Town

State/Province

ZIP/Postal Code

Country

GP phone number

GP email address

Leave this field blank