HLS Gloucestershire - I'd like support

I'd Like Support

Once you click ‘submit’, your completed form and all the information it contains are safely encrypted and transferred to a secure nhs.net email account.

Please note that we aim to contact all clients within two working days of us receiving their referral.

Thank you for your co-operation

Your details:

Name

Gender

Date of Birth

Contact Number

Email Address By ticking this box I confirm I do not have an email address for verification

Postal Address

Support required in relation to (tick as many boxes as apply):

Smoking in Pregnancy

Pregnancy weight management

Smoking

Alcohol

Weight Management

Physical Activity

Do you have a long term condition?

Additional Comments

Client Consent

I consent to being referred to the Gloucestershire 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 Gloucestershire 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
Accurately monitor your progress throughout the programme
Ensure sure that our services remain current and effective

Your data may be used by the following subcontractors for the delivery of our services:

Slimming World
To allow us to develop anonymised reports for issuing to our commissioners, Gloucestershire City Council, and the Department of Health
Enabling us to offer you a better service by sharing your health information with your GP

Acceptance

I consent for my personal details to be held by Gloucestershire 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 Ltd are obliged to uphold.

I consent for the service to use my details for statistical and analysis purposes 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.

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.

Make a Referral

I'd Like Support