Social Prescribing Webform MOBY 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. 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.For patients of the following GP Practices only:Yardley Wood Health Centre, Victoria Road Surgery, Wake Green Surgery, Baldwins Lane Surgery, Greenridge Surgery, Poplar Primary Care Centre, GP surgery *Yardley Wood Health CentreVictoria Road SurgeryWake Green SurgeryBaldwins Lane SurgeryGreenridge SurgeryPoplar Primary Care CentreName *FirstLastContact NumberEmail AddressAddress Line 1CityState / Province / RegionPostal CodeDate 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 Name *Emergency Contact Telephone Number *Overall, 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)Move It Or Lose It (Exercise)Moseley Park Walking GroupEdgbaston Health Programme (Weight Loss)Moseley Football Group (Youth Group)Sparkhill Walk & SwimMoseley Road Baths (Swimming)Be Active SchemeSaheli Activities (Physical activity sessions)Swanshurst Walking GroupTai Chi - Balsall HeathBikes on Prescription*These activities will be based at your GP surgeryVirtual Activity Interest (multiple choice) Relaxation Thurs 7:30pm-8:30pm (delivery by Beat It Percussion) Virtual Chair-based Exercise - Fri 11amVirtual Coffee Morning = Drop-inDementia Online SupportALL these activities will take place online and you will need access to internetSocial/Educational Activity - select all that apply Growing Together - Gardening GroupCarers Support Share Shack at Hobs Moat Community Cafe (Thurs 12pm-1:30pm)Acocks Green - Men's ShedAcocks Green in BloomMoseley & Kings Heath ShedBillesley ArkBillesley Knit & NatterVictoria Road Community GardenBody Mind SpiritBarber Institute - A Space to Explore ArtThe Peoples Orchestra - ChoirHealthcare Support GroupSouth Yardley Library - Health & Wellbeing ClubBefriending ServiceCraft Group - Kings HeathSaheli Activities (Social/Educational sessions)Financial/Benefits/Social Support - Select all that applyFood supportFinance and Benefits AdviceEmployment Training Program - Thrive into workEarly Help - Family SupportMeals Delivery Service - Emergency FoodHousing / HomelessnessAddition - Drug/AlcoholTick 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.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 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, 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.Submit