East Birmingham Social Prescribing Referral Form Please enable JavaScript in your browser to complete this form.Social prescribing is an approach that connects people to activities, groups, and services in their community to meet the practical, social and emotional needs that affect their health and wellbeing.Dear user, please ensure you select the GP practice that you are registered with otherwise the referral will be delayed in being allocated to the relevant Social Prescribing Link Worker. Once you have completed the form, you will be contacted in due course. For any queries, please email [email protected]. Your Name *FirstLastAddress with postcode: *Your Telephone/Mobile contact number: *Email address:Please select the GP Practice you are registered with: *Garretts Green Lane SurgeryIridium Medical PracticePoolway Medical CentreSwan Medical CentreThe Sheldon PracticeDownsfield PracticeChurch Road Surgery Eden courtFirs SurgeryHarlequin SurgeryHodge Hill Family Practice Mirfield Surgery Tile Cross Surgery (Church branch)All Saints Medical CentreDudley ParkStratford HouseNB: Without selecting a GP Practice, this referral will not be allocated to a social prescribing link worker. Date of birth: *Gender: *MaleFemaleOtherDropdown *Asian:Afghani - A1Asian:Bangladeshi - AAAsian: British Asian - A3Asian: Chinese - C2Asian: Filipino - C3Asian: Indian Other - A9Asian: Indian Sikh - A8Asian: Kashmiri - A5Asian: Other Asian - A7Asian: Pakistani - ACAsian: Sri Lankan - ABAsian: Vietnamese - D1Black: Any Other Black/African/Caribbean background - BABlack: African - B7Black: Black British - B2Black: Caribbean - B8Black: Somali - B4Mixed: Other Mixed - C9Mixed: White & Asian - M1Mixed: White & Black Caribbean/African - WBOther Ethnicity: Arab - C1Other Ethnicity: Iranian - C5Other Ethnicity: Kurdish - C8Other Ethnicity: Other - D3Other Ethnicity: Yemini - D2White: Baltic States - WA White:English/Welsh/Scottish/Northern Irish/British Irish - W8White: Gypsy or Irish Traveller - W9White: Jewish - V1White: Other White - W7White: Other White European - W6White: Polish - W4Unknown/Undisclosed - UReason for referral / Support required:ExerciseWeightDepression/AnxietyFrequent GP Long-term Health Condition Healthy EatingChallenging Social CircumstancesIsolation/LonelinessLearning, Training, EmploymentOther (please state below)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 Overall, to what extent do you feel that the things you do in your life are worthwhile? Selected Value: 0 Overall, how happy did you feel yesterday? Selected Value: 0 On a scale where 0 is “not at all anxious” and 10 is “completely anxious”, overall, how anxious did you feel yesterday? Selected Value: 0 Tick to confirm: *You will be contacted by a 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 boxTick to confirm: *The 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. You will only be signed up if there are relevant online activities suited to you.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, Bordesley East PCN (Only whichever is relevant to you). 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