Professional Referral

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

Thank you for your co-operation

Healthy Lifestyles Service Referral Form

Referrer's Consent (to be completed by referrer.)

Referrer’s details:

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

Client’s details:

To maximise staff and client safety, please outline any known client issues (e.g. disabilities, learning difficulties, mental health issues or aggressive/violent behaviour). Please state if these are current or historic.

Client Consent (to be confirmed by the client)

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

I recommend for the above person to be referred to the Gloucestershire Healthy Lifestyles Service to receive onward signposting and support.