Weight Management on Referral – Tier 2 Healthy Weight Programme (adult and families)
Patient Referral Form 
By completing this referral form, you confirm that you have consulted the South Gloucestershire Healthy Weight Pathway below and consider the Tier 2 Healthy Weight Service to be the most appropriate offer for your patient. 

All fields must be completed, or the referral may be rejected

Healthy Weight Pathway – South Gloucestershire

Tier 1 
Self help 
for individuals ready to start making changes on their own

¤ No referral needed
•	NHS Weight Loss Plan
•	Weight Management Webinars
•	Self-help resources

Tier 2 
Targeted Support 
community-based programmes with professional support

¤ Referral via South Glos Weight Management Referral Form or direct GP referral (see each service)
•	Tier 2 Healthy Weight Programme (adults & families) –      South Glos Weight Management Referral Form
•	Health & Happiness Hubs – GP or self-referral 
•	NHS Digital Weight Management Programme – GP 
•	NHS Diabetes Prevention Programme – GP 
•	Diabetes and Nutrition Service – GP 
•	NHS Type 2 Diabetes Path to Remission Programme – GP 

Tier 3 
Specialist Support
clinical support including surgery 

¤ Direct GP referral 
•	Oviva 
•	North Bristol Trust 

Please complete the corresponding section for an adult or family Tier 2 Healthy Weight Service referral: 
•	Refer to section one for an adult referral to the Healthy Weight Programme (adults - 18 years+)
or
•	Refer to section two for a family referral to the Healthy Weight Programme (families - aged 5-17 years)
Section one – Tier 2 Adult Healthy Weight Referral
Patient details: 
First Name:Calling Name  	Last Name:Surname 	
Address:Home Full Address (stacked) 	
Postcode:Home Address Postcode 	Date of birth: Date of Birth 	
Telephone: Patient Home Telephone 	Consent for future contact:   (please tick)	
Email address:Patient E-mail Address 
If the patient has access to email, then this is essential for the referral process.  	
Special considerations:      

Eligibility criteria: 
1.	Please tick to confirm that the patient meets the following criteria 
•	Aged 18 years or above
•	Has a BMI ≥ 30 (BMI ≥ 28 with co-morbidities or BMI ≥ 27.5 if Black-African, African-Caribbean, and Asian family origin)
•	Patient is clinically stable
•	Patient is committed to complete a healthy weight intervention
•	Patient is not pregnant
•	Patient does not have a history of or an ongoing eating disorder

2.	Patient height, weight and BMI *this must be a recent BMI within last 3 months*
Height-  
Height 
Weight –
Weight 
BMI –
BMI 

If BMI is ≥ 27.5 is the patient:
Black African, African-Caribbean, South Asian or Chinese?        Yes           No  
If BMI is ≥ 28 does the patient have co-morbidities?                    Yes           No   (if ‘Yes’, please state      …………………..)                                                                                                                                                                                          ***  Please note – we are unable to accept referrals for patients with a BMI which is ≤ 30 unless they meet the above criteria  ***

Equalities monitoring:

Ethnic Origin:

 Ethnic Origin      
	
Gender:       

 Gender 
	
Do you consider yourself to be disabled?
      No
      Yes – Physical impairment, such as difficulty using arms or mobility issues which may mean using a     wheelchair or crutches. 
      Yes – Sensory impairment, such as being blind / having a serious visual impairment or being deaf / have a serious hearing impairment. 
      Yes – Mental health condition, such as depression, anxiety or schizophrenia. 
      Yes – Learning disability/difficulty, such as Down’s Syndrome, dyslexia, dyspraxia or cognitive impairment such as autistic spectrum disorder. 
       Yes – Long standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsy. 
     Yes – Other (please state)       ……………………………………
      Prefer not to say.
If yes, please tell us how this affects the way that you access or use services     ……………………………………………………………………	
Sexual Orientation 
Bisexual             Gay man              Gay woman/lesbian           Heterosexual               Other            Prefer not to say      	
Religion and/or Belief

Religion 

Prefer not to say              Unknown      Other       	
Do you identify as a transgender person? 
Yes             No              Prefer not to say           	
Which of the following forms of financial support do you currently receive or are in the process of applying for:
       Income support
       Housing Benefit
       Employment support allowance
      Working Tax Credit
       Pension Credit
       Universal credit
       Job Seekers Allowance
       Council Tax Reduction
       None of the above
       Prefer not to say	
Are you currently or have you previously served in the UK Armed Forces?
       No
       Yes - currently serving
       Yes – previously served in Regular Armed Forces
       Yes – previously served in Reserve Armed Forces	
Care experience – as a child did you spend any time in local authority care? 
       No
       Yes 
       Prefer not to say	
What is your current employment status?
 Full time student
 Intermediate
 Managerial and professional
 Never worked or long term unemployed
 Retired or Home carer
 Routine and manual
 Sick or disabled and unable to work
 Unknown
 Prefer not to say	

Clinical confirmation and consent:
I recommend that the patient named above be referred to the Tier 2 Healthy Weight Programme provided by the Public Health and Wellbeing Division (PHWD) at South Gloucestershire Council (SGC). I confirm that I have assessed the patient, and to the best of my knowledge, they meet the appropriate referral criteria and there are no medical reasons preventing their participation.
I confirm that I have discussed the service and the Privacy Notice (see ‘Information for patients’) with the patient, and that verbal consent for this referral has been obtained. I also agree to notify the PHWD at SGC of any relevant changes to the patient's health that may affect their participation.
Signed:      	
Surgery/Health Centre:Organisation Full Address (stacked) 	

Once the referral form is complete, please provide the patient with a copy of the ‘Information for Patients’ section and securely email the completed form to OneYou@southglos.gov.uk.

Consultations 
Problems 
Medication 
Allergies 
Values and Investigations 
Smoking 
Alcohol Consumption 

………………………………………………………………………………………………………………………………………….

Section two – Tier 2 Family Healthy Weight Referral
Child details:
First Name:     	Last Name:     	
Gender: 
Female   Male   Other     Prefer Not To Say 	Date of birth:      	
 
Parent details: 
First Name:     	Last Name:     	
Address:     	
Postcode:     	Date of birth:      	
Telephone:      	Consent for future contact:  (please tick)	
Email address:     
If the patient has access to email, then this is essential for the referral process.  	
Special considerations:      	

Eligibility criteria: 
1.	Please tick to confirm that the family meets the following criteria 
•	Child is aged 5-17 years. 
•	Child has a BMI ≥91st centile with no co-morbidity *this must be a recent BMI*
•	Family is committed to complete a healthy weight intervention.
•	Child or parent does not have a history of or an ongoing eating disorder.
Equalities monitoring:
Child

Ethnic Origin: 
Asian
      Asian/Asian British Bangladeshi 
      Asian/Asian British Indian 
      Asian/Asian British Pakistani 
      Asian/Asian British Chinese 
      Asian/Asian British other background
Black
       Black/Black British African 
       Black/Black British Caribbean 
       Black/Black British other
Mixed White 
       Mixed White and Black Carribean 
       Mixed White and Black African 
       Mixed White and Asian 
       Mixed other background
White
       White Roma  
       White English/Welsh/Scottish/Northern Irish/British
       White Irish
       White other 
Other 
       Unknown 
       Other ethnic groups – Arab
       Any other ethnic group
       Prefer not to say
      Gypsy or Traveller of Irish Heritage	
Disability 
   No 
   Yes – Physical impairment, such as difficulty using arms or mobility issues which may mean using a wheelchair or crutches.  
   Yes – Sensory impairment, such as being blind / having a serious visual impairment   
or being deaf / have a serious hearing impairment.  
   Yes – Mental health condition, such as depression, anxiety or schizophrenia.  
   Yes – Learning disability/difficulty, such as Down’s Syndrome, dyslexia, dyspraxia or cognitive impairment such as autistic spectrum disorder.  
    Yes – Long standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsy.  
   Yes – Other (please state)      ……………………………………
    Prefer not to say. 
If yes, please tell us how this affects the way that your child accesses or uses services     ………………………………………………………	

Parent

Ethnic Origin: 
Asian
      Asian/Asian British Bangladeshi 
      Asian/Asian British Indian 
      Asian/Asian British Pakistani 
      Asian/Asian British Chinese 
      Asian/Asian British other background
Black
       Black/Black British African 
      Black/Black British Caribbean 
      Black/Black British other
Mixed White 
       Mixed White and Black Carribean 
       Mixed White and Black African 
       Mixed White and Asian 
       Mixed other background
White
       White Roma  
       White English/Welsh/Scottish/Northern Irish/British
       White Irish
       White other 
Other 
       Unknown 
       Other ethnic groups – Arab
       Any other ethnic group
       Prefer not to say
       Gypsy or Traveller of Irish Heritage	
Gender:        
Female             Male              Other            Prefer not to say     	
Do you consider yourself to be disabled?
      No
      Yes – Physical impairment, such as difficulty using arms or mobility issues which may mean using a     wheelchair or crutches. 
      Yes – Sensory impairment, such as being blind / having a serious visual impairment or being deaf / have a serious hearing impairment. 
      Yes – Mental health condition, such as depression, anxiety or schizophrenia. 
      Yes – Learning disability/difficulty, such as Down’s Syndrome, dyslexia, dyspraxia or cognitive impairment such as autistic spectrum disorder. 
       Yes – Long standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsy. 
     Yes – Other (please state)      …………………………………………………
      Prefer not to say.
If yes, please tell us how this affects the way that you access or use services      ………………………………………………………………………	
Sexual Orientation 
Bisexual             Gay man              Gay woman/lesbian           Heterosexual                Other            Prefer not to say      	
Religion and/or Belief
Buddhist             Christian              Hindu           Jewish                Muslim           Sikh    
No religion          Any other religion, please state      ………….                     Prefer not to say              	
Do you identify as a transgender person? 
Yes             No              Prefer not to say           	
Which of the following forms of financial support do you currently receive or are in the process of applying for:
       Income support
       Housing Benefit
       Employment support allowance
       Working Tax Credit
       Pension Credit
       Universal credit
       Job Seekers Allowance
       Council Tax Reduction
       None of the above
       Prefer not to say	
Are you currently or have you previously served in the UK Armed Forces?
       No
       Yes - currently serving
       Yes – previously served in Regular Armed Forces
       Yes – previously served in Reserve Armed Forces	
Care experience – as a child did you spend any time in local authority care? 
       No
       Yes 
       Prefer not to say	
What is your current employment status?
 Full time student
 Intermediate
 Managerial and professional
 Never worked or long term unemployed
 Retired or Home carer
 Routine and manual
 Sick or disabled and unable to work
 Unknown
 Prefer not to say	

Clinical confirmation and consent:
I recommend that the patient named above be referred to the Tier 2 Healthy Weight Programme provided by the Public Health and Wellbeing Division (PHWD) at South Gloucestershire Council (SGC). I confirm that I have assessed the patient, and to the best of my knowledge, they meet the appropriate referral criteria and there are no medical reasons preventing their participation.
I confirm that I have discussed the service and the Privacy Notice (see ‘Information for patients’) with the patient, and that verbal consent for this referral has been obtained. I also agree to notify the PHWD at SGC of any relevant changes to the patient's health that may affect their participation.
Signed:      	
Surgery/Health Centre: Organisation Full Address (stacked) 	

Once the referral form is complete, please provide the patient with a copy of the ‘Information for Patients’ section and securely email the completed form to healthyweight@circadiantrust.org 

…………………………………………………………………………………………………………………………………..

Information for patients
What is the Healthy Weight Service? 
This is a local programme delivered by South Gloucestershire Active Lifestyle Centres in partnership with South Gloucestershire Council (SGC). The programme aims to support individuals in developing healthier habits through physical activity and group support sessions.  

How much does it cost?
There is no cost associated with this referral and the service offered are free of charge.  

What happens next?
Adult referral: Once your healthcare professional has completed the referral form it will be sent to the team at SGC. The SGC team will then contact you via email or telephone to discuss the referral. If you have any questions in the meantime, visit the One You website.  
Family referral: Once your healthcare professional has completed the referral form it will be sent to the team at the Active Lifestyle Centres. The team will then contact you via the telephone to discuss the referral. If you have any questions in the meantime, please contact the team on 01454279968 or email healthyweight@circadiantrust.org.  

What do we do with your data?
We will use your personal information to provide you with a service. We will share your personal information only with your referrer and locally commissioned healthy weight service providers, but no one else without your permission. 

Upon completion of the service your personal information will be kept securely for 7 years and 20 years for child data.
Statistical information about people who use the service may be retained for longer than this, but this would not identify you.

If you would like to request access to the information we hold about you, or have any concerns about how we use your information please complete a Data Subject Rights request form or contact us at OneYou@southglos.gov.uk

More information about how we manage your personal information is available from www.southglos.gov.uk/privacy.

If you do not have a computer and would like more information, please contact the One You South Gloucestershire team on  01454 865337.