Healthy Peterborough Service Self-Referral Form Email this form to OR Post “Freepost HEALTHY PETERBOROUGH” OR Fax to 01733286835 OR Call at 0800 376 56 55/01733 590064. Client details: Full name: Address: Postcode: Telephone: Email: Date of Birth: NHS number: Ethnicity: GP name: GP address: Tick the appropriate Occupation Code; Full-time student Never Worked Managerial/Professional Home Carer Long-term unemployed Intermediate Retired Sick/Disabled/Unable to work Routine/Manual Prisoner Self Employed Unable to Code Tick the appropriate service(s) you would like □ □ Want to lose weight – SU4L Want to stop smoking □ □ Would like to be more active - LGM Want a NHS Health Check □ □ I am concerned about my child’s weight Would like a 1-2-1 Health Trainer Client’s consent “I □ To being contacted via any of the contact information I have provided consent…” □ A voicemail to be left on my phone if I am unavailable □ Being involved in the programme and contacted for referral/s □ My GP being contacted □ My information being shared for the purpose of evaluation Client Signature: …………………………………………… Date: ……………………………………. Referrer’s details Referrer’s name: Referrer’s organisation: Date of referral: Signature:
Healthy Peterborough Service Self-Referral Form Email this form to OR Post “Freepost HEALTHY PETERBOROUGH” OR Fax to 01733286835 OR Call at 0800 376 56 55/01733 590064. Client details: Full name: Address: Postcode: Telephone: Email: Date of Birth: NHS number: Ethnicity: GP name: GP address: Tick the appropriate Occupation Code; Full-time student Never Worked Managerial/Professional Home Carer Long-term unemployed Intermediate Retired Sick/Disabled/Unable to work Routine/Manual Prisoner Self Employed Unable to Code Tick the appropriate service(s) you would like Want to lose weight – SU4L □ Want to stop smoking □ Would like to be more active - LGM □ Want a NHS Health Check □ I am concerned about my child’s weight □ Would like a 1-2-1 Health Trainer □ Client’s consent “I consent…” To being contacted via any of the contact information I have provided □ A voicemail to be left on my phone if I am unavailable □ Being involved in the programme and contacted for referral/s □ My GP being contacted □ My information being shared for the purpose of evaluation □ Client Signature: …………………………………………… Date: ……………………………………. Referrer’s details Referrer’s name: Referrer’s organisation: Date of referral: Signature:
healthy_peterborough_self-referral_form_v2.0.docx