1. First name
2. Last name
3. Date of birth
4. What is the participant's gender?
5. Does the participant have access to a computer or tablet with internet connectivity? Or is someone able to provide this access for them?
Please note that HBH is an online study, with limited capacity for in-person assessments.
6. What is their primary language? (please select)
Note: Primary language refers to the language they will be able to complete an assessment in.
7. Has the participant been diagnosed with dementia (of any type)?
This includes diagnoses such as Alzheimer's disease, Vascular Dementia, Parkinson's disease dementia, Dementia with Lewy bodies, or other forms of dementia.
10. Is the participant currently experiencing symptoms of any of the following health conditions that require treatment?
- Alcohol use disorder
- Substance use disorder
- Untreated mental health condition (e.g., Schizophrenia, bipolar disorder, major depressive disorder)
11. Phone Number
12. Email Address
13. Does the participant currently reside in Australia?
14. Is the participant aware of this referral?
15. Is the participant able to be contacted directly regarding this referral?
21. To your knowledge, is the participant being referred currently enrolled in another research study?
22. GP Name
23. GP Clinic Name
24. Is the participant's GP aware of this referral?
25. Name
26. Organisation
27. Relationship to participant being referred
28. Phone Number
29. Email Address
30. Fax (if applicable)
31. Reason for referral (please briefly describe)