Llwchwr Healthy Lifestyles Project Referral Form – Adult Form (18+)

This programme is for individuals that are over the age of 18 years, and who are registered to a GP Practice within the Llwchwr Cluster (i.e. Estuary Group Practice - including Gowerton Medical Centre, Penclawdd Health Centre and Penybryn Surgery; Princess Street Surgery, Talybont Surgery and Ty’r Felin Surgery).

Exclusions – The project cannot accept individuals who:
* Are under the age of 18 years
* Are not registered to a GP Practice within the Llwchwr Cluster
* Have been prescribed injectables for weight loss
* Are currently pregnant
* Are currently receiving support from an eating disorder service

If the individual meets the above criteria and does not fall into the exclusion criteria, please provide with the information requested below:

Reasons for referral?

Reason: (required)

Personal Details:

Name: (required)

Address (incl Postcode): (required)

Home phone number: (required)

Mobile number:

Email address: (required)

Registered GP Surgery: (required)

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If you are completing this form on behalf of someone else, please complete the details below:

Referrer Details:

Name:

Organisation:

Role:

Contact telephone number:

Email address:

Permission to refer

The project can only accept referrals for another person if you have their explicit permission to do so. Please tick this box to confirm that you have the individuals permission to refer them to the project. (required)

I have permission to refer the individual to the projectI do not have permission to refer the individual to the project

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SCVS takes data protection very seriously. The information given will be held safely by SCVS for 6 years following the end of the project (in line with other public services).

The information will be used to manage our relationship with you as a recipient of the Llwchwr Healthy Lifestyles Project.

A copy of the full SCVS, Privacy Statement can be found by visiting www.scvs.org.uk/privacy

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