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Wellbeing Coach – Professional Referral

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

Client Details

The client gives permission to contact them by
Do they feel ready and able to make positive changes to support their wellbeing?

Referrer Details

Equalities Questions (please ask your client these questions)

How do you describe your gender? *
Do you consider yourself to be transgender or as having a transgender history?
What is your sexual orientation?
Do you have a religion?
What is your ethnicity?
Do you see yourself as disabled?
Are you a carer?
Are you currently or have you previously served in the UK Armed Forces?
Which of the following describes your highest level of qualification?
Do you have any dependents living in your household in the following age groups?
Which of the following forms of financial support do you currently receive or are in the process of applying for?
What is your employment status?