Referral Form

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

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Healthy Lifestyles Service Referral Form

Referrer's Consent (to be completed by referrer.)

Referrer’s details (e.g. referring organisation name & address)

Client Name:

Clients Ethnicity:

Date of Birth:

Client’s contact details:

Contact No.:

Email Address:

By ticking this box I confirm I do not have an email address for verification

Postal Address:

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

I confirm that I have assessed this person, and to my knowledge there is no medical reason why he/she should not be referred.

I confirm that I have discussed this referral, and the reasoning for it, with the person named above

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:

Known Issues (including any Long Term Conditions):

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

Referrer’s name and date of referral:

Date of Referral:

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

Smoking

NHS Health Check

Weight

Alcohol

Physical Activity

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.

Please tick this box if you consent to this service

Introduction

Your data is required to:-

Assist us in delivering the most suitable lifestyles services to meet your specific needs
For us to be able to accurately monitor your progress throughout the programme
To help us to make sure that our services remain current and affective
Your data may use the following subcontracts for the delivery of our services
- GP surgeries in the Coventry area
- Pharmacies in the Coventry area
- Slimming World
To allow us to develop anonymised reports for issuing to our commissioners, Coventry City Council, and the Department of Health
Enable us to offer you a better service to you by sharing your health information with your GP

Acceptance

I consent for my personal details to be held by Coventry Healthy Lifestyle Services. I understand the service will hold my personal data for up to five years, which will allow me to re-enter the service during that time. I understand I have the right to ask for my data to be deleted from the service records at any time. I understand that anything I disclose to a health coach will be treated in the strictest confidence and will only be shared with other services with my permission or for legal reasons that ICE Creates are obliged to uphold.

I consent for the service to use my details for statistical and analysis purpose only, and understand that my confidentiality will be maintained always, and all information will be stored in accordance with ICE Creates Ltd data protection policy and procedures, and that my personal identifiable details will not be used in any reports without my permission. Further information can be found here Link to ‘Obtaining Consent’ Link to ‘Managing Consent’

Obtaining Consent

We have checked that consent is one of the appropriate lawful basis for processing and have made the request for consent prominent and separate from our terms and conditions when we ask people to positively opt in.

We don’t use pre-ticked boxes, or any other type of consent by default in fact we use clear, plain language that is easy to understand and inform you specifically why we want the data and what we’re going to do with it.

You have the right to withdraw your consent without detriment to you and you have the right to refuse to consent without detriment. You also have the right to request a copy of the information we hold about you in an easy to read and transferable format

If you refuse to provide consent it will be difficult for us to provide a lifestyle services to you for clinical and safety reasons, in addition, we must obtain and maintain accurate details about you.

Managing Consent

We record consent by storing when and how we were provided with your consent and exactly what you were told at the time.

We will not share your data with other service providers without your agreement and your data will not be transferred outside of the UK.

We regularly review consent to check that the relationship, the processing and the purposes have not changed.

We have processes in place to refresh consent at appropriate intervals. It is an easy process for individuals to withdraw their consent at any time, and we act on withdrawals of consent as soon as we can. Additionally, we don’t penalise individuals who wish to withdraw consent.

I give permission for my referrer to be kept informed of my progress.

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.

Referring for weight management related issues TBC

Referring for alcohol related issues

For alcohol related referrals, the Healthy Lifestyles Service is able to support people who are drinking outside the Government guidelines and want to cut down, but do not require specialised support to do so. Individuals who are dependent on alcohol should be considered for more specialised services (tier 3).

CGL are the specialist service (tier 3) that provide support to those that are dependent on alcohol, and offer treatment/recovery support. They can be contacted on 02476 010241 or email coventry.referrals@cgl.cjsm.net or you can find their referral form at the following link
https://changegrowlive.org/content/CGL-coventry/professionals-referral-form

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Referral Form

Referral Form

Healthy Lifestyles Service Referral Form

Client’s contact details:

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)

Important information for referrers for alcohol & weight related issues

Referring for weight management related issues TBC

Referring for alcohol related issues