Self-Referral Form to NHS services Self-Referral Form Please complete the below form and ALL information will be passed onto the Health and Wellbeing Coaches to review and process referral if suitable. General DetailsName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Address Street Address Address Line 2 City Postcode Date of birth Month Day Year Contact NumberAre you Pregnant? Yes No N/A Is an interpreter required? Yes No If so, for which language? OptionalWhich surgery in the Newark and Sherwood PCN are you a patient at? OptionalThe Fountain Medical CentreCollingham Medical CentreHounsfield SurgeryLombard Medical CentreSouthwell Medical CentreBarnby Gate SurgeryBalderton Pimary Care CentreDo you consent to your information being shared with the health and wellbeing coaches?If not, we won’t be able to accept your referral. Yes No Please state your your long-term health conditionTick all that apply. Prediabetes Type 2 Diabetes High Cholesterol COPD BMI 30 or above Fibromyalgia Mild/Moderate Mental Health conditions Lack of motivation around health & wellbeing Stress management Other long-term health condition We cannot accept your referral. Additional information relevant to the referral e.g., medical conditions, motivation, other support services involved, communication needs etc.,To be eligible for the service, you must have a long-term health condition.