Wellbeing Coach – Professional Referral – Southern Brooks Community Partnerships

This form is for referring a client to a Wellbeing Coach at Southern Brooks.

If you would like to make a referral for yourself instead, please use this form.

For more information about our service, including eligibility criteria, click here to see our FAQ

Referral Form

Wellbeing Coach Professional Referral

Date of Referral

Client Details

Client - Full Name *

Client - Date of Birth (Must be 18 or over)

Client - Telephone Number *

Client - Email Address

The client gives permission to contact them by

Which GP surgery are they registered at? (The client must either be registered at a GP surgery in South Gloucestershire or a resident of South Gloucestershire)

Client - Address

Client - Post Code

What changes would they like to make to their wellbeing?

Do they feel ready and able to make positive changes to support their wellbeing?

Yes

Don't know

Please give us some background information that would be helpful for the Wellbeing Coach. (Including any access needs, and whether any other services are involved) *

Are there any safeguarding risks we should be aware of? *

Referrer Details

Referrer - Name *

Referrer - Telephone Number

Referrer - Email

Referrer - Job Title and Organisation *

I confirm that the client consented to this referral

If you are human, leave this field blank.

Wellbeing Coach – Professional Referral

Referral Form

Client Details

Referrer Details

Equalities Questions (please ask your client these questions)

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