Health & Wellbeing Service Referral Form
The Voluntary Norfolk Health and Wellbeing service is for those who are facing challenges including newly diagnosed long-term conditions, recovering from a period of ill-health or injury, or living with a condition that may have caused social isolation or a loss of independence. The service offers the chance to work with a volunteer to improve their physical and mental wellbeing. For an initial three-month partnership, our volunteers visit clients at home, or in public, and offer support to help people adjust to changing life events, allowing them to regain their confidence and motivation so they can manage their own health and wellbeing. Use this form to check whether the person is suitable for the Health and Wellbeing service and to make a referral. This form covers four areas: 1. Criteria required for client to be accepted 2. Exclusion criteria; needs which cannot be met by this service 3. Client and referral details 4. Your details as the referrer Fields marked with an * are required
You must answer YES for us to accept this referral
You must answer YES for us to accept this referral
You must answer YES for us to accept this referral
You must answer YES for us to accept this referral
You must answer NO for us to accept this referral
You must answer NO for us to accept this referral
You must answer NO for us to accept this referral
You must answer NO for us to accept this referral
What is an NHS Number and how can I find it? www.nhs.uk/using-the-nhs/about-the-nhs/what-is-an-nhs-number/

Please be assured that we treat all information as confidential and the person’s information will not be shared outside of the programme without their permission. For more information on how we handle data please refer to Our Privacy Policy.