Health & Wellbeing Service Referral Form
The Health and Wellbeing service is provided by volunteers who work with clients to improve physical and emotional health, wellbeing and independence. The emphasis is on a partnership, with the volunteer and client working together to set and achieve goals. 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.