Social Prescribing Webform Bournville & Northfield PCN Please enable JavaScript in your browser to complete this form.The Active Wellbeing Society delivers a wide range of free activities and support services for adults in partnership with your GP practice. Please complete the form below and select the areas you are interested in. Once the form is received, your Social Prescribing Link Worker will send you the related information and further details. PLEASE ENSURE THE SECTIONS WITH AN ASTERISK (*) ARE COMPLETED, OTHERWISE THE FORM WILL NOT SUBMIT - THANK YOUPlease select the GP surgery you are registered at: *College Green MPSt Heliers MPWychall Lane SurgeryFor patients of the following GP Practices only: College Green Medical Practice, St. Heliers Medical Practice or Wychall Lane SurgeryPlease provide your NHS number:Name *FirstLastEmail Contact Number: *First Line of Address & PostcodeDate of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity *White BritishWhite IrishWhite PolishWhite otherAsian BangladeshAsian IndianAsian PakistaniAsian ChineseAsian otherBlack AfricanBlack CaribbeanBlack otherMixed Asian & BlackMixed Asian & WhiteMixed Black & WhiteAny other ethnicityRather not sayDo you have a disability *YesNoEmergency Contact person (Name) *Emergency contact number *How would you rate your ability managing your own health & wellbeing? Selected Value: 1 1 - Not able, 2 - A little able, 3 - Quite able, 4 - Very ableOverall, how satisfied are you with your life nowadays? Selected Value: 0 Use the slider to select on a scale 0-10Overall, 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 0-10Overall, how happy did you feel yesterday? Selected Value: 0 Use the slider to select on a scale 0-10Overall, how anxious did you feel yesterday? Selected Value: 0 On a scale where 0 is “not at all anxious” and 10 is “completely anxious”, Physical Activity Interest (multiple choice)Be Active – Birmingham City Council Leisure CentresCotteridge Park (Outdoor Activities)Exercise and mobility (Limited spaces & Incurs Small Fee)Learn to ride (Eco Brum)Seated yoga (Chatham Place - Limited Spaces)Tai Chi (Indoor and Outdoor Groups)Cycling Groups (Hawkesley and Cotteridge)Yoga (In the park)Virtual Activity Interest (multiple choice) TAWS - Virtual Chair Based Exercise TAWS - Cardio CombatTAWS - Low Impact Seated ExerciseTAWS - Afro BeatsTAWS - Dance FitnessTAWS - Salsa DancingBeezee Bodies - Healthy LivingSport England - Get Active At HomeSense Touch Base - (Yoga, Dance, Pilates) Limited Spaces available Meditation and Mindfulness appsOnline support for mental health - weblinksALL these activities will take place online and you will need access to internet (Except Sense which requires telephone access only)Community Support Interest (multiple choice)Thrive into Work, employment support for people with a mental health condition or disabilityThe Project, benefits, debt and housing supportNorthfield Community Partnership – community connection and employment supportB31 FoodbankTick to confirm *I agree to register for a Wellbeing CardThe Wellbeing Card is required to enable you to access the free activities through The Active Wellbeing Society. You will be issued with a membership card known as Wellbeing Card which you will receive in the post. Want to get active outdoors? Why not take part in our outdoor activities in Parks, Streets and open green spaces? There are free outdoor activities in over 80 parks and green spaces throughout the year. So join us and try something different from walking, running and cycling to Zumba and tai chi. If you live or work in Birmingham, you can get active for free and there’s something for everyone. The Wellbeing Card can be used to access all of The Active Wellbeing Society’s free services- including activities on Zoom, borrowing items at Share Shacks and much more. To sign yourself up for a card please visit: https://www.kineticinsightpro.com/birmingham/ To find out more info visit: https://theaws.co.uk/join-us/wellbeing-card/Tick to confirm *You will be contact by your social prescribing link worker via email or/and SMS with information on your chosen support services . Your information request will be updated on to your medical records – if you give consent please tick the boxTick 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 or Our Health Partnership. 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.Submit