Wellbeing Service referral form

The service will support tenants to better understand the actions they can take to manage their health and wellbeing by making and maintaining positive changes to their lifestyle.

Tenants will be supported to address the underlying issues which prevent them from adopting healthy lifestyles and the emphasis is on supporting them to develop their skills.

Please note that we are not a Crisis service. If you feel your situation is deteriorating or urgent you can contact:

  • your GP; or the NHS helpline on 111 or go to the Accident and Emergency Department to access Crisis services; or
  • You can call the Samaritans on 116 123 who can help you talk through whatever is troubling you, find the answers that are right for you, and offer support.

In order for your referral to be accepted, all information fields on this referral form must be filled in.

If you need any help filling in this form please contact the team on 01977 724403.

Background information
Other agencies involved

Please give details of any services that you are currently, or have been involved with. This includes pending referrals.

Referrer Details
Details of person requiring support (please complete all fields)

If living with children please insert their ages

What can the Wellbeing Team help you with? Lifestyle

Health issues

Emotional wellbeing

Life skills

Relationship issues

Housing issues

Reason for referral

Where referral relates to mental health please describe symptoms experienced over the previous two weeks.

Where referral relates to mental health please describe symptoms experienced over the previous two weeks.

Is a joint visit required?

We use information about you to tailor our service to your needs, to protect you if you are deemed vulnerable, to provide appropriate housing and to ensure the safety and enjoyment of the areas in and around WDH property. For example, if you are disabled and use a wheelchair, we will use this information to provide appropriately modified housing, or, if you are struggling to pay your rent we may use your income and expense details to check if you could be entitled to certain benefits to help with this.

We will also use the Personal Data we hold about you to contact you when necessary about the administration of your tenancy or the service we provide you.

There may be instances where we use your data without your consent. This will only be in rare circumstances where there is a need to protect you, other members of the public or WDH have a legal, contractual or public duty to disclose this information about you.

Consent to the referral

You agree to a referral to the Wellbeing Team to be made and to engage with the team to achieve positive outcomes.

You agree to WDH checking NHS / Mental Health records to assist with your support?

You agree that through the process of our support, if appropriate, your personal details may be passed on to suitable partners to enable us to provide you with the relevant support.

You have the right to withdraw this consent at any time but you must be aware that we may not be able to then provide you with support.

For further information on how we use your personal data, see the WDH Privacy Policy. If you would like a copy, we can email it out to you.