Social Prescribing Self-Referral Form MMP2 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. Please complete this form and a social prescribing link worker will contact you in due course. Your name *FirstLastAddress with postcode: *Telephone/Mobile contact number: *Email address:Please select the GP Practice you are registered with: *Stratford House SurgeryDudley Park MedicalDate 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 - UWhat type of carer are you?Full TimePart TimeWhat is your relationship with the person you look after?Wife / Husband / PartnerMother / FatherSon / DaughterOther, please specify belowPlease specify other:Have you been diagnosed with any medical conditions? (You can select more than one)Diabetes MellitusHypertensionAny type of ArthritisEpilepsyAsthma, COPD, Respiratory DiseaseCoeliac DiseaseThyroid or any other metabolic conditionsDepressionAnxietyOther, Please specify belowPlease specify other medical conditions here:What is the age group of the person you look after?0-10 years11-24 years25-39 years40-55 years56-75 yearsOver 75 yearsWhat type of patient do you look after? (Tick more than one if necessary)Dementia (vascular, Alzheimer’s Disease, Lewy’s)CancerAny type of severe arthritisChallenging behaviorLearning disabilityOther: Please specify which one belowOther Disability - Please specify which one:Which of the following are you currently experiencing difficulties with?Gas and electricityAccessing benefits (knowing whether you are entitled)DebtsIsolationLow moodHousing difficulties (making arrangements in the house, or moving to another accommodation)Accessing transportationAccessing housekeeping servicesHave you heard about the social prescribing service in your surgery?YesNoServices in the community:Hay Hall’s community caféBig Feed ProjectOnline Exercise Sessions - The Active Wellbeing Society (TAWS)All Saints Church (Small Heath – Gardening Grow and Connect)Walking Groups - TAWSAckers Adventure – Skiing, Canoeing, FishingSports Club South Yardley Library: Swan Coffee Bar - Every Monday and Friday, 10am—12noon.South Yardley Library: Brew with the Crew - Come and chat with members of your local Community Police team, Friday 8th September 10—11am.South Yardley Library: Citizens Advice Outreach - Benefits Advice available every Monday, by appointment only. Referral forms available from the Library counter.South Yardley Library: Thursday Crafternoon - Every Thursday 2—4.30pm. A friendly and relaxed group open to anyone aged 16 and over. All needlecrafts welcome, small charges apply.South Yardley LIbrary: Over 50s Health Programme - From 15th September. Aged 50+? On Fridays from 10.30 to 12 we are hosting a weekly health programme offering sound relaxation and gentle exercise. All free, and refreshments provided. Come and give it a go, and meet some new people! Book with Usman on 07443039458.South Yardley Library: NEW Lunch Club - Tuesday 12th and Tuesday 19th September 12.30—3pm, in association with Saheli Hub we are offering a FREE lunch for 18-49 year olds with additional needs, however all welcome! Vegetarian option available.South Yardley LIbrary: Lace Makers - Saturday 9th September 10am—4pm. New members welcome, please enquire.South Yardley Library: Book Club - Saturday 30th September 2.15—4.30pm, this month’s theme is “Historical Fiction”. Everyone welcome, bring your books, views and opinions.Art for Wellbeing at Acocks Green LibraryAcocks green Baptist church: Tuesday of each month carers group, cuppa and chatLunch club YardleySister’s Project Re engage for over 75 years oldHome Instead - TrainingsSelect as many as your requireHow 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 Your surgery is planning drop-in sessions to support Carers in your area, and we would like to know which days could we consider. (Please pick 2 options)Monday morning (anytime between 9:00 – 12:00 hrs)Monday afternoon (anytime between 12:00 – 15:00 hrs)Tuesday morning (anytime between 9:00 – 12:00 hrs)Tuesday afternoon (anytime between 12:00 – 15:00 hrs)Wednesday morning (anytime between 9:00 – 12:00 hrs)Wednesday afternoon (anytime between 12:00 – 15:00 hrs)Thursday morning (anytime between 9:00 – 12:00 hrs)Thursday afternoon (anytime between 12:00 – 15:00 hrs)Friday morning (anytime between 9:00 – 12:00 hrs)Friday afternoon (anytime between 12:00 – 15:00 hrs)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, Midlands Medical 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