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

Important information: Please complete referrer's details and 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 click here to confirm you agree to our Consent to Process Personal Data.
Please tick this box if you agree?  


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