Southern Brooks Community Partnerships

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

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?
What is your employment status?