Langworthy Cornerstone
0161 213 1920
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WELLBEING ENABLER - REFERRAL FORM
The aim of the Wellbeing Enabler is to work on a one to one basis over an extended period to improve the health and wellbeing of people living in the local area (Claremont, Langworthy, Weaste and Seedley: CLOWS) who have consistent low mood which is affecting their motivation and ability to participate fully in life.
Participants will generally have related factors such as excessive drinking, weight, lack of physical activity, smoking, isolation, damaging behaviour (gambling, drugs, and other ‘compensating’ behaviours), inability to form and sustain supportive relationships etc.
If the participant has severe mental health difficulties or any risk issues requiring specialist support please do not use this referral form and instead contact your local mental health support agencies.
I confirm that I have read and understood the role of the Wellbeing Enabler in supporting this participant
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yes
REFERRER'S DETAILS
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Indicates required field
Referrer's name
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First
Last
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GP Practice
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Cornerstone Medical Practice
The Willows Medical Centre
Pendleton Medical Centre
Salford Medical Centre
The Quays Practice
Orient Road Medical Practice
Sorrel Bank (Bolton Rd Surgery) Medical Practice
Sorrel Bank Victoria Rd Surgery
Clarendon Medical Practice
Clarendon Branch Angel Medical Practice
Ordsall Health Surgery
Langworthy Medical Practice
University of Salford Health Centre
The Height General Practice
Select one
Referrer's occupation/role
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Referrer's Organisation
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Referrer's landline number
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Referrer's mobile number
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Referrer's email
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PARTICIPANT'S DETAILS
Participant's name
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First
Last
Participant's landline number
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Participant's mobile number
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Participant's email
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Participant's address
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Participant's postcode
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Participant's date of birth
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Please give some details about the participant.
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Is there anything else we need to know that might be useful?
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Does the participant experience any other related difficulties. Please tick all that apply.
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Excessive drinking
weight issues
lack of physical activity
smoking
social isolation
damaging behaviour (gambling, drugs and other compensating behaviours)
inability to form/sustain supportive relationships
low mood
Other (please describe)
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Are there any notable risk issues we should be aware of?
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Yes
No
If "yes" please give more details.
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I confirm that I have had permission from the participant for this referral
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Yes
Submit
