Healthy Lifestyles Service Referral Form

Healthy Lifestyle support is for:

Myself Someone else

Your details:

Once you click 'submit', your completed form and all the information it contains are safely encrypted and transferred to a secure database.

Please note that we aim to contact you within two full working days of receiving your information.

Thank you for your co-operation

Midwife support:

I'm Currently Pregnant

I've given birth and my child is under the age of 2

Neither

My named midwife

Baby delivery date

Clear

1:1 support is only available for stop smoking and/or weight management if your BMI is between 30 and 40.
To check if your BMI is in range, tick Healthy Eating below and fill in your weight and height. If your BMI is over 40 you are still eligible for group support.

My named midwife

Baby delivery date

Clear

1:1 support is only available for stop smoking and/or weight management if your BMI is between 30 and 40.
To check if your BMI is in range, tick Healthy Eating below and fill in your weight and height. If your BMI is over 40 you are still eligible for group support.

First name(s)

Last name

Gender

Date of birth

Contact number

Mobile number

Email address

Postal address

Postcode

GP name (if known)

GP practice (if known)

Please tick the box if any of these apply to you:

Long Term Condition

Mental Health problem

Learning disability

Physical disability

Additional comments

How did you find out about Healthy Lifestyles?

Support required in relation to

(tick as many boxes as apply):

Smoking

Alcohol

Weight management

Physical activity

Height (cm)

or feet inches

Weight (kg)

or st lbs

BMI

Your BMI is 0

Client consent

I consent to being referred to the Gloucestershire 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 Gloucestershire 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.

Consent to process personal data

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
Accurately monitor your progress throughout the programme
Ensure sure that our services remain current and effective

Your data may be used by the following subcontractors for the delivery of our services:

Slimming World
WW (Weight Watchers)
To allow us to develop anonymised reports for issuing to our commissioners, Gloucestershire City Council, and the Department of Health
Enabling us to offer you a better service by sharing your health information with your GP

Acceptance

I consent for my personal details to be held by Gloucestershire 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 Ltd are obliged to uphold.

I consent for the service to use my details for statistical and analysis purposes 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.

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.

For the individual being referred

I can obtain further information about how my personal data is processed on the HLS privacy notice, which includes the right to withdraw consent to this referral and sharing myprogress with the referrer. This can be reached at hlsglos.org/privacy and a copy is also available at the Healthy Lifestyles Gloucestershire Office upon request.

Referrer’s details:

Your name

Your organisation

Your job title

Your email

Your tel no

Support required in relation to

(tick as many boxes as apply):

Smoking

Alcohol

Weight management

Physical activity

Please select preferred Service for weight management

Height (cm)

or feet inches

Weight (kg)

or st lbs

BMI

Your BMI is 0

Client’s details:

Midwife support:

Antenatal

Postnatal

Neither

Named midwife

Named midwife email

Baby delivery date

Clear

1:1 support available for Smoking Cessation and/or Weight Management if BMI is between 30 and 40

Named midwife

Named midwife email

Baby delivery date

Clear

1:1 support available for Smoking Cessation and/or Weight Management if BMI is between 30 and 40

First name(s)

Last name

Gender

Date of birth

Contact number

Mobile number

Postal address

Email address

Postcode

Please tick the box if any of these apply to the individual:

Long Term Condition

Mental Health problem

Learning disability

Physical disability

Known issues/additional comments

Long term conditions. Please tick if any of these apply to the person

1. Cardiovascular disease or risk e.g. Coronary heart disease; Stroke / TIA; Raised blood cholesterol or triglycerides

2. Hypertension

3. Diabetes or Insulin resistance / impaired glucose tolerance (IGT)

4. Respiratory condition e.g. sleep apnoea, asthma, chronic obstructive pulmonary disease

5. Personal or family of history of breast, endometrial or colon cancer

6. Musculoskeletal condition e.g. Osteoarthritis, chronic back pain.

7. Mental health condition e.g. depression, anxiety

8. Awaiting surgery

Other: please specify below

Client consent (to be confirmed by client)

I consent to being referred to the Gloucestershire 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 Gloucestershire 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.

Consent to process personal data

Please tick this box if you the individual has consented to this service’

Introduction

Your data is required to:

Assist us in delivering the most suitable lifestyles services to meet your specific needs
Accurately monitor your progress throughout the programme
Ensure sure that our services remain current and effective

Your data may be used by the following subcontractors for the delivery of our services:

Slimming World
To allow us to develop anonymised reports for issuing to our commissioners, Gloucestershire City Council, and the Department of Health
Enabling us to offer you a better service by sharing your health information with your GP

Acceptance

I consent for my personal details to be held by Gloucestershire 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 Ltd are obliged to uphold.

I consent for the service to use my details for statistical and analysis purposes 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.

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.

For the individual being referred

I can obtain further information about how my personal data is processed on the HLS privacy notice, which includes the right to withdraw consent to this referral and sharing myprogress with the referrer. This can be reached at hlsglos.org/privacy and a copy is also available at the Healthy Lifestyles Gloucestershire Office upon request.

I recommend for the above person to be referred to the Gloucestershire 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

As I have been referred to the weight management referral scheme, the nature and purpose of which has been explained by my referrer. I understand that this will require the release of relevant personal information about myself to the Gloucestershire Healthy Lifestyle Service (HLS) and Slimming World (SW).

I would like to be kept up to date on the progress of this referral should the subject give their consent