Professional Referral Thank you for referring into Healthy You’s Integrated Lifestyle service. Before you submit, please check the below eligibility criteria for the service to ensure appropriate referral. Adult Weight Management Health Trainer Mental Health – Health Trainer Eastern European Health Trainer Service Diabetes Health Trainer Carers – Health Trainer Alcohol Reduction Falls Prevention Health Checks Stop Smoking Professional Referral Patients Information First Name * Last Name * Date of Birth * Gender Male Female Gender not listedGender not listed NHS Number * Service Select a serviceAdult Weight ManagementHealth CheckStop SmokingStop Smoking in PregnancyFalls (for people aged 65+)Health TrainerMental Health – Health trainerDiabetes – Health TrainerEastern European – Health TrainerCarer – Health TrainerAlcohol Reduction – Health TrainerHealthy Lifestyles Does your patient require an interpreter? Yes No If yes, what language? Patient contact information Please enter at least an email address or phone number (ideally both) Phone Email Patient address Address * Address Address Address City City County County Postcode Postcode Referring Organisation What type of organisation are your referring from? * Please selectCommunity ServicesDrug and AlcoholGPHealth VisitingHospitalLocal AuthorityMaternityMental HealthPharmacyOtherSchool Nurses What type of organisation are your referring from? Name of your Organisation? * Name of the referrer * Referrer’s Email * Additional Notes Data Consent * I confirm I have consent from the named person to upload their personal information. Contact Consent * I confirm I have consent from the named person for them to be contacted by Everyone Health. (Contact will only be made for follow ups on treatments and outcome data) Captcha If you are human, leave this field blank. Submit
