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Referral Form

Referral Form

Once you click ‘submit’, all your information will be safely transferred to a secure nhs.net email account.

Please note that we aim to contact all clients within two working days of us receiving their referral.

Thank you for your co-operation


Healthy Lifestyles Service Referral Form

Referrer's Consent (to be completed by referrer.)
Referrer’s details (e.g. referring organisation name & address)

Client’s contact details:

I recommend for the above person to be referred to the Coventry Healthy Lifestyles Service to receive onward signposting and support.

To maximise staff and client safety, please outline any known client issues (e.g. long term conditions, disabilities, learning difficulties, mental health issues or aggressive/violent behaviour)? Please state if these are current or historic?

Known issues:

Important information: Please complete referrer's details and date of referral

Support required in relation to (tick as many boxes as apply):

Client Consent (to be confirmed by the client)

I consent to being referred to the Coventry Healthy Lifestyles Service. The nature and purpose of which has been explained by my referrer.

I consent to the release of relevant personal information about myself to the Coventry Healthy Lifestyles Service. I understand this information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controller is my referrer.

I understand that I have (i) the right to change my mind about being referred to the service and to withdraw consent and (ii) right of access to my information.

Important information for referrers for alcohol & weight related issues

Please be aware that the Healthy Lifestyles Service is a behaviour change service (tier 1 & 2), and supports people that wish to make lifestyle changes, but do not require specialised support to do so. If referring individuals with more complex issues, these should be referred to tier 3 & 4 services.