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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
First name(s)
Last name
Gender
Male
Female
Other Gender Identification
Non-Binary
Date of birth
Contact number
Mobile number
Postal address
Email address
Postcode
GP name (if known)
GP practice (if known)
Additional comments
How did you find out about Healthy Lifestyles?
How did you find out about Healthy Lifestyles?
Support required in relation to
(tick as many boxes as apply):
Smoking
Alcohol
Weight
Physical activity
Referrer’s details:
Referral Source
General Medical Practitioner Practice
Carer/Relative
Employer
Emergency Care Department (including Minor injuries and Walk in Centres)
Acute hospital Inpatient/Outpatient Department
Community Health Service (same or other Health Care provider)
Dental Practice
National Screening Programme
Educational Establishment
Local Authority Social Services
Hospice
Care home
Police
Courts
Probation Service
Prison Health Service
Asylum Service
Telephone or Electronic Access Service
Voluntary Sector
Independent Sector
Ambulance Service
Mental Health Service
Pharmacy
Self Referral
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
Client’s details:
First name(s)
Last name
Gender
Male
Female
Other Gender Identification
Non-Binary
Date of birth
Contact number
Mobile number
Postal address
Email address
Postcode
Please tick the box if any of these apply to the individual:
Known issues/additional comments
NHS Number (if known)
NHS Number (if known)
I do not know my NHS number
I do not know my NHS number
Ethnic Category
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated
Not Known
Ethnic Category
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated
Not Known
Employment Status
Employed
Unemployed and actively seeking work
Undertaking full or part time education or training as a student and not working or actively seeking work
Long term sick or disabled, or receiving government sickness and disability benefits
Looking after the family or home as a homemaker and not working or actively seeking work
Not receiving government sickness and disability benefits and not working or actively seeking work
Unpaid voluntary work and not working or actively seeking work
Retired
Not stated
Employment Status
Employed
Unemployed and actively seeking work
Undertaking full or part time education or training as a student and not working or actively seeking work
Long term sick or disabled, or receiving government sickness and disability benefits
Looking after the family or home as a homemaker and not working or actively seeking work
Not receiving government sickness and disability benefits and not working or actively seeking work
Unpaid voluntary work and not working or actively seeking work
Retired
Not stated
Height (cm)
or
feet
inches
Height (cm)
or
feet
inches
Weight (kg)
or
st
lbs
Weight (kg)
or
st
lbs
Are you pregnant? (tick for yes)
Are you Pregnant? (tick for yes)
Disability Self Report (tick any that apply)
Long Term Condition
Mental Health Condition
Learning Disability
Physical Disability
Disability Type
Behavioural and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (learning disability)
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self-Care and Continence
Progressive Conditions and Physical Health (Such as HIV, Cancer, Multiple sclerosis, fits etc)
Sight
Speech
Other
No Disability
Not Stated (person asked but declined to provide a response)
Client consent
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.
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
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.
Client consent (to be confirmed by 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.
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
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 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
I give permission for my referrer to be kept informed of my progress
Thanks for completing this assessment