Wellbeing

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 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 *

yes

REFERRER'S DETAILS

* Indicates required field

Referrer's name *

First

Last

Referrer's occupation/role *

Referrer's Organisation *

Referrer's landline number *

Referrer's mobile number *

Referrer's email *

PARTICIPANT'S DETAILS

Participant's name *

First

Last

Participant's landline number *

Participant's mobile number *

Participant's email *

Participant's address *

Participant's postcode *

Please give some details about the participant. *

Is there anything else we need to know that might be useful? *

Does the participant experience any other related difficulties. Please tick all that apply. *

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

Other (please describe) *

I confirm that I have had permission from the participant for this referral *

Yes

Submit