wdh

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?

Consent to the referral