Dementia navigation referral · Trellis

Enrollment

For Trellis staff:

If enrolling: Use the link below to create a person record and enrollment pre-filled with the collected referral data. This referral will be automatically linked to the enrollment. When finished, set the referral status to Completed and select Eligible: Enrollment created as the closure reason.

Enroll in dementia navigation

This link will automatically search Cumulus for a matching person. If one is not found, the a new person can be created, pre-filled with demographics, with an enrollment created as well. CTRL+Click on link to open link in a new tab and keep this referral open.

Details

Full name of person being referred: Unanswered
Date of birth of person being referred: Unanswered
Phone number of person being referred: Unanswered
Email of person being referred: Unanswered
Address of person being referred: Unanswered
Person's primary language: Unanswered

If not enrolling: Set the referral status to Completed and select the appropriate closure reason.

Closure details

Referral closure reason *

Select only one

Eligible: Enrollment created Eligible: Enrollment not created Ineligible Invalid referral submission Not enough information, submitted in error, etc.

Making a referral

Whether you’re a healthcare professional, community organization, family member, or friend, making a referral—or self-referral—is easy. Complete the form below, and a Care Ecosystem representative will follow up within 2 business days to conduct a brief assessment and help you determine the right level of support.

Program eligibility

The Care Ecosystem program of Trellis requires specific eligibility criteria. Please confirm the person you are referring meets all three of the following requirements:

1. Is the primary caregiver (18+) for a person living with dementia OR is a person living alone with dementia. No formal diagnosis required.

2. Lives in the Twin Cities seven-county metro community (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, or Washington county). The program is unable to accommodate those living outside the Twin Cities metro area at this time.

3. Resides in a home setting (private residence). The program is unable to accommodate those living in residential care or nursing care environments at this time.

Does the person meet all 3 requirements of the Care Ecosystem dementia support program? *

Select only one

Yes No

Thank you for your interest in the Care Ecosystem dementia support program at Trellis. Unfortunately, your referral does not meet the current eligibility requirements of this specific program. Trellis offers additional free support services through the Senior LinkAge Line including caregiver support, Medicare counseling, long-term care counseling and resource navigation. Senior LinkAge Line specialists can be reached at 1-800-333-2433, Monday – Friday from 8:00am to 4:30pm.

Information of person being referred

Person being referred *

Select only one

Caregiver (age 18+) for a person with dementia A person living with dementia or experiencing signs of dementia

Full name *

Date of birth *

Phone number *

Address *

Start typing the address to auto-populate

Is the person's primary language English? *

Select only one

Yes No Unknown

Other primary language *

Does the person need language interpretation services? *

Select only one

Yes No Unknown

Please note: this free phone-based service uses a third-party professional interpretation provider.

Is there a preferred time to contact this person? *

Select only one

Morning Afternoon Unsure

Information of person filling out referral

Full name *

Phone number *

Relationship to person being referred *

Describe the other relationship to the person being referred *

Provide details about the family relationship *

Title within the organization *

Healthcare hospital *

Other Healthcare hospital *

Healthcare clinic *

Other Healthcare clinic *

Healthcare organization name *

How did you hear about the Care Ecosystem program from Trellis?

Additional details

Any other information you'd like to share?

By submitting this form, you confirm that the person being referred (yourself or someone else) has given consent to share their information and understands that Trellis Care Ecosystem will contact them to offer support or services pending eligibility review.

Dementia navigation referral - Trellis website referral submissionsTrellis website referral submissions

Enrollment

Closure details

Making a referral

Program eligibility

Information of person being referred

Information of person filling out referral

Additional details

Dementia navigation referral - Trellis website referral submissions
Trellis website referral submissions