Health & Wellbeing Professional Referral Form

Are you a patient looking to Self refer into the Health and Wellbeing Service?

If you are a patient looking to self-refer to the Aylesbury Central PCN Health & Wellbeing service, please click 'Self-Refer'

Self-Refer

Please only complete the below form if you are a healthcare professional referring a patient into the Health & Wellbeing service

Please select the organisation you are referring from below *

Whitehill Surgery
Berrycroft Community Health Centre
Other

Patient's Name *

First

Last

Patient's Date of Birth *

Patient's NHS Number

Patient's Contact number *

Patient's preferred language

If not listed, select Other.

Patient's Email address

Referring Clinician

Has the patient identified any family or carers they would like involved in this referral on their behalf?

Any safeguarding concerns?

Additional information/intended outcomes

Consent

I give consent to the Health and Wellbeing Service holding information about me
I agree to information being recorded following our meeting, being shared with others who are or could be involved in my care, this will help them understand your needs and may avoid repetition
I give consent to this service contacting my next of kin, in case of an emergency or major concern
I give consent for the service to contact me via the email address detailed above, to include sensitive and personal information
I give consent to allowing the health and wellbeing service sharing my story for the benefits of other patients and the training of future health coaches in training
I give consent to the health coach managing this patients support, the ability to forward refer onto one of the following services to maximise this patients progress

In order to help you, the Health and Wellbeing service needs to store some information about you, this is treated as confidential and will only be shared with the appropriate agencies agreed with you.

Date / Time of Referral

Date

Time

Providing NHS services

Midshire Business Park, Smeaton Close, HP19 8HL

Sorry! Requests are currently closed due to staff shortages

Please leave your name and e-mail address to be notified when submissions are open again

By submitting your name and email address you agree to Aylesbury Central PCN to contact you regarding Health & Wellbeing coaching.

An empowering and fun programme that explores the most effective methods to lose weight and keep it off. On the course you will address concerns that you have with your lifestyle, such as with your diet and physical activity levels.

We passionately believe in quality education and in long-term sustainable behaviour change and not short-term diet or lifestyle fads. We look at health holistically, offering choices with flexible options. This approach delivers multiple benefits well beyond weight loss including improving sleep quality, stress management, relationship with food and preventing future health conditions.

Features of the programme

Lifestyle & wellbeing education programme covering weight loss, managing stress, sleep quality, preventing future health conditions
Flexible dietary approaches: Low carbohydrate, Mediterranean, Intermittent fasting, Real food and snacking avoidance
12 x Online Group Sessions
Includes a printed Weight & Wellbeing Programme Handbook