Health Coaching

Use this form to refer yourself

Your full name (required)

Date of birth (required)

Gender

Your NHS number (if you know it)

Email address (if you have one)

Phone number

Would you prefer to be contacted by email or phone? We will try this method first (required)
—Please choose an option—Email preferredPhone preferredNo preference

If we phone and you don’t answer, is it OK for us to leave a message?
—Please choose an option—YesNo

What suspected/confirmed respiratory related condition(s) would you like to refer yourself for?
AsthmaBronchitisChronic Obstructive Pulmonary Disorder (COPD)PneumoniaOther (please state below)

Use this space to tell us about any additional needs you may have, or anything else you think we need to know before contacting you

I have completed this form myself, and have read the Privacy Notice Relating to Health Coach Referrals. I understand that the LDCVS Health Coach will make three attempts to contact me to arrange a meeting, after which this referral will be closed and I will need to submit a new referral if I still require support. (required)

Use this form if you are referring someone else. For example you may be referring a patient, a client, or a friend or family member. You must have obtained their consent to make the referral.

About the person being referred
Their title (e.g. Mr/Mrs/Ms/Dr etc.)

Their full name (required)

Their date of birth (required)

Their NHS number (if you know it)

Their gender

Their home address

Their email address (if they have one)

Their phone number

Would they prefer to be contacted by email or phone? We will try this method first (required)
—Please choose an option—Email preferredPhone preferredNo preference

If we phone and they don’t answer, is it OK for us to leave a message?
—Please choose an option—YesNo

Their next of kin or other contact details if applicable

Their ethnicity

Their religion

Their languages spoken and preferred language

Is the patient or their carer likely to cause a risk to staff safety? If yes, please state how

When was their most recent visit to the GP or hospital services, if known?

What suspected/confirmed respiratory related condition(s) would you like to refer them for?
AsthmaBronchitisChronic Obstructive Pulmonary Disorder (COPD)PneumoniaOther (please state below)

Use this space to tell us about their relevant medical history and current medications

Use this space to tell us about any additional needs they may have, or anything else you or they think we need to know before contacting them

Consent to Share Information (required)
In order to provide the support the person being referred requires it may be necessary to share information between the Health and Wellbeing Coach provider and the person who referred them, such as their GP or a hospital department. This will only take place with their consent and they may withdraw this consent at any time. Services will only share information that is necessary for meeting their support needs. This may include sharing their assessment, progress, and care/support plan information as well as any on-going communication.

I have obtained the individual's consent that information about their support may be shared between the services that are delivering support. They understand that services will only share information that is necessary for meeting their support needs and that they have the right to withdraw their consent at any point.I have not obtained consent or the individual being referred has not given consent that information about their support may be shared between the services that are delivering support.

About you – the person making this referral
Your relationship to the person being referred (required)

Your contact details (name, phone number, postal address and email address) (required)

I have completed this form to refer someone else, and have obtained their consent to do so, drawing their attention to the Privacy Notice Relating to Health Coach Referrals. I understand that the LDCVS Health Coach will make three attempts to contact them to arrange a meeting, after which this referral will be closed and I will need to submit a new referral if they still require support. (required)