Refer to us

Some patients or clients may need a little extra help to access the support on offer for a healthier
lifestyle.

A practitioner from our One You South Gloucestershire team is on hand to help. They will discuss your
patient or client’s needs with them. Your patient/client might for example need help to read about
the benefits of ‘Moving More’ from our website. On the other hand, they might want to discuss the
range of options for mental health and wellbeing with the wellbeing team. For those who need more
help in making a lifestyle change such as losing weight or stop smoking, we offer telephone support
to take them through the change.

If you have a service for stopping smoking at your GP practice, you need to use your in house
service before referring to us.

Tell us about the patient you would like to refer

About the person you would like to refer

Is the referral part of a:

About the person you would like to refer

Date of birth

For example, 01 08 1997

About the person you would like to refer

We use this to help link you to local services in your area


About the person you would like to refer

Are they registered at a South Gloucestershire GP Surgery

About the person you would like to refer

Which of the following topics are they interested in?

Tick all that apply

About the person you would like to refer

About them

The information they provide enables us to check that we give a good and fair service to everyone and
identify
how we could potentially improve our services to them in the future.

All their answers will be treated in the strictest confidence and will only be used to monitor and help
improve our services.

You can read more about our monitoring in our privacy policy.

Equalities monitoring

What is their ethnic group?

Includes any Asian background, for example, Bangladeshi, Chinese, Indian, Pakistani


or

Includes any Black background


or

Includes any Mixed background



or

Includes any White background



or

Includes any other ethnic group

or

Equalities monitoring

What is their sexual orientation?

or

Equalities monitoring

Are they a carer for someone?

or

Equalities monitoring

What is their current employment status?

or

Equalities monitoring

What is their religion?

or

Equalities monitoring

Do they have a disability?

This could be a physical or sensory impairment, mental health condition, learning disability or
difficulty, long standing illness or health condition.



or

About the person you would like to refer

How would they prefer to be contacted about this referral?

About them

The information you provide enables us to check that we give a good and fair service to everyone and identify
how we could potentially improve our services to you in the future.

All your answers will be treated in the strictest confidence and will only be used to monitor and help
improve our services.

You can read more about our monitoring in our privacy policy.

Equalities monitoring

What is their ethnic group?

Includes any Asian background, for example, Bangladeshi, Chinese, Indian, Pakistani



or

Includes any Black background



or

Includes any Mixed background



or

Includes any White background



or

Inclues any other ethnic group

or

Equalities monitoring

What is their sexual orientation?

or

Equalities monitoring

Are they a carer for someone?

or

Equalities monitoring

What is their current employment status?

or

Equalities monitoring

What is their religion?

Equalities monitoring

Do they have a disability physically or mentally?

How did they hear about us?
Other

Submit referral

The information provided will be used to provide the service. It will only be shared with our partners
involved with delivering One You South Gloucestershire, in accordance with South Gloucestershire Council's privacy notice.

Your patient or client may tell us at any time if they would like to stop the service or update their
details.

Once we receive the referral, we aim to contact your patient or client within two working days. We regret
we will not be able to confirm receipt of referrals.

If your patient or client is registered with a South Gloucestershire GP, we will give feedback to their
practice on whether they receive support from us as a result. We will not give any details of the
support provided.

Select Yes if you agree to these terms and conditions.

As your patient or client does not give consent for us to receive and use their data, call us on
01454 865337 so we can help with the enquiry.