Health trainers referral form

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Are you over 18? Do you want to:

• Improve your general wellbeing
• Build your self confidence and motivation
• Reduce or stop smoking
• Eat healthier food and be a healthy weight
• Be more active
• Drink less alcohol?

Privacy Notice

Fields marked * are required.

Contact information

First Name * (mandatory field)

Last Name * (mandatory field)

Gender: * (mandatory field)Please choose... Male Female

Please tick to confirm that you are over 18 * (mandatory field)

Address * (mandatory field)

Contact number

Email address

Preferred contact method: * (mandatory field)Please choose... Daytime number Mobile Email Post

Please indicate what health area(s) you are looking for support with:

Healthy eating

Physical activity

Working towards a healthy weight

Smoking

Physical activity

Alcohol intake

Other

About this service

Where did you hear about this service? * (mandatory field)

Confirmation

In keeping with the Data Protection Act, the details on this form will be entered onto the central database and shared with your local health trainer. They will not be used for any other purpose and will be destroyed after two years.

If you would like to receive an email copy of your completed form please make sure you have provided one above

Tick to receive email copy of sent form

I have read and accept the terms of the privacy statement *

Security question * Select '11' from the list
Why do I need to answer this? (mandatory field)Please choose...8311

Last updated: 19 June 2018