TAWS Social Prescribing Web Form – The Active Wellbeing Society

The Active Wellbeing Society delivers a wide range of free activities and support services for adults in partnership with your GP practice. Your Social Prescribing Link Worker based at your surgery would like to offer you the support to complete the form below by selecting the areas you are interested in.

Complete the registration form below to access free activity sessions delivered by The Active Wellbeing Society and partners in your local area.

GP surgery

Name *

First

Last

Contact Number *

Email

Address *

Address Line 1

City

State / Province / Region

Postal Code

Ethnicity *

Date of Birth *//

Do you have a disability *

Emergency Contact name

Emergency contact number

Overall, how satisfied are you with your life nowadays?

Selected Value: 0

Use the slider to select on a scale 0-10

Overall, to what extent do you feel that the things you do in your life are worthwhile?

Selected Value: 0

Use the slider to select on a scale 0-10

Overall, how happy did you feel yesterday?

Selected Value: 0

Use the slider to select on a scale 0-10

Overall, how anxious did you feel yesterday?

Selected Value: 0

On a scale where 0 is “not at all anxious” and 10 is “completely anxious”,

Social Activity Interest (multiple choice)

Managing Stress - Topics Change Weekly *
Mindfulness: Topics Change Weekly *
Learning English (ESOL classes) *
Health and Wellbeing Course *
Type 2 Diabetes Education Programme *

* These activities will be based at your GP surgery

Physical Activity Interest (multiple choice)

Walk and Talk *
Green Fingers Group (gardening)
Cycling *
Boxing (delivered by Pat Benson Boxing Academy)
Gardening at All Saints Church Small Heath (hot food provided)

*These activities will be based at your GP surgery

Virtual Activity Interest (multiple choice)

Lets Connect – a fun social group, all ages
Relaxation (delivery by Beat It Percussion)
Chair Based Exercise
Diabetes Education Programme
Carer support

ALL these activities will take place online and you will need access to internet

Social support needed - select all that apply

Tick to confirm *

I agree to register for a Wellbeing Card

The Wellbeing Card is required to enable you to access the free activities. You will be issued with a membership card known as Wellbeing Card which you will receive in the post.

Tick to confirm *

You will be contact by your social prescribing link worker via email-SMS with your chosen support services information. Your information request will be updated on to your medical records – if you give consent please tick the box- .

Tick to confirm *

I agree to the data protection policy of The Active Wellbeing Society. To view this policy please review below:

Privacy Notice How information about you will be used Information you provide is collected and stored securely by The Active Wellbeing Society Limited (community benefit society registered with the ICO; Reg. No. ZA266982), who provide services on behalf of Birmingham City Council, Sport England, Our Health Partnership or Bordesley East PCN. We collect this information to enable us to administer the membership we hold with you, to provide better services, to promote public health and physical activity and monitor the effectiveness of our programmes, to maintain our accounts and records, to prevent fraud and misuse of public funds and to report to our funders. We will keep this information during the time of your involvement with our services and for a period of 3 years afterwards. We may share anonymous information about you with our partner organisations and funders, in order to provide you with appropriate services, to monitor outcomes related to physical activity and healthy lifestyles and to facilitate research and insight. We and our partners will hold this information in confidence and comply with all our responsibilities under the General Data Protection Regulation and Data Protection Act. By signing up, you agree to these terms. You have a right to withdraw your consent at any time at any time by contacting us on 0121 728 7030 or emailing [email protected]. If you would like a copy of our Data Protection Policy please visit http://www.theaws.org/privacy-notice Alternatively, you can find out more about your rights or complain to the Information Commissioner’s Office at ico.org.uk.