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Health trainers referral form

Customer notice

Please tell us what you think about our website, we welcome your feedback.

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?

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Contact information

First Name * (mandatory field)

Last Name * (mandatory field)

Gender: * (mandatory field)

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

Address * (mandatory field)

Contact number

Email address

Preferred contact method: * (mandatory field)

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

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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)

Contact Details (LiveLink)

Multiple Contacts:
eMail: health.trainers@wiltshire.gov.uk
Telephone:

0300 0034566

Out of hours:
Fax:
Postal Address:

Health trainers
Public health
County hall
Bythesea Road
Trowbridge
BA14 8JN

In Person:
DX:

Last updated: 19 June 2018

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Tel: 0300 0034566

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Health trainers
Public health
County hall
Bythesea Road
Trowbridge
BA14 8JN

health.trainers@wiltshire.gov.uk

Health trainers referral form

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