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Quit Vaping (12-18 years)
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Know Your Blood Pressure
About Us
Services
Weight Management
Physical Activity
Stop Smoking
Quit Vaping (12-18 years)
Health Checks
Health & Wellbeing Coaching
Cook & Eat
Training & Workshops
Additional Services
Campaigns
Events
Professionals
Know Your Blood Pressure
About Us
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Referral Form Update
Do you speak English? (If you cannot speak English we can arrange for translation)
(Required)
Please select one
Yes, I can speak English
No, I can't speak English
What language can you speak?
Do you work, live, study, or have a GP in Hounslow?
(Required)
Please select one
Yes
No
Sorry, we can only accept residents or people who work, study or have a GP in the Hounslow area. We suggest contacting your local council or authority and asking them about health or well-being support services.
Are you signing up for yourself or for someone?
(Required)
Please select one
I'm referring somone
I'm signing up for myself
Name of Referrer/Parent/Guardian
(Required)
Referrer's Name/Parent's or Guardian's name (if referring a child under 16)
Referring Organisation
Not required if Parent or Guardian
Email address for Referrer/Parent/Guardian
(Required)
Thank you. The next questions relate to the person you are referring.
Which service would you like to sign up for?
(Required)
Eat well
Health Coaching
Stop Smoking
Weight Management
To be eligible for our weight management programmes you must meet our criteria for body mass index (BMI). Please calculate your BMI using this calculator https://www.nhs.uk/health-assessment-tools/calculate-your-body-mass-index and enter your age and result in the boxes below.
Which category does the person being referred fall into?
(Required)
Please select one
Aged 5-17 – BMI is 91st centile or above
Aged 5-17 – BMI is less than the 91st centile
Aged 18+ BMI is greater than or equal to 30
Aged 18+ and of Black African, African-Caribbean or Asian origin - BMI is greater than or equal to 27.5
Aged 18+ BMI is less than 30
Aged 18+ and of Black African, African-Caribbean or Asian origin – BMI is less than 27.5
You are not eligible as your weight is in the healthy range. Don't worry! We have lots of information and guidance to help support your health and wellbeing. Visit our website to have a look: https://healthyhounslow.co.uk Why not subscribe to our newsletter to receive health and wellbeing tips direct to your inbox? We'll also keep you updated on any local events and campaigns.
Email
Which one of our services would you like to sign up for?
(Required)
Eat well
Health Coaching
Stop Smoking
Weight Management
To be eligible for our weight management programmes you must meet our criteria for body mass index (BMI). Please calculate your BMI using this calculator https://www.nhs.uk/health-assessment-tools/calculate-your-body-mass-index/ and enter your age and result in the boxes below.
Which BMI/BMI Centile do you fall into?
(Required)
Please select one
Aged 5-17 - BMI is 91st centile or above
Aged 5-17 - BMI is less than the 91st centile
Aged 18+ BMI is greater than or equal to 30
Aged 18+ and of Black African, African-Caribbean or Asian origin - BMI is greater than or equal to 27.5
Aged 18+ BMI is less than 30
Aged 18+ and of Black African, African-Caribbean or Asian origin – BMI is less than 27.5
You are not eligible as your weight is in the healthy range. Don't worry! We have lots of information and guidance to help support your health and wellbeing. Visit our website to have a look: https://healthyhounslow.co.uk/
Are you interested in joining one of our other services?
(Required)
Please choose one
Yes
No
At Healthy Hounslow, we are proud to dedicate hundreds of hours each month to support Hounslow residents in improving their health. We invest our time and resources to ensure that you have access to the help you need. In return, we kindly ask that you sign up only if you're certain you'll be able to commit to weekly sessions to improve your health. By doing so, you’re helping us continue to offer this support more promptly to all residents who rely on our services.
Please choose one
I'm ready to commit
I'm not ready to commit
If you are interested in one of our other services, please change your selection on the question 'Are you interested in any of our other services?'
Why not subscribe to our newsletter to receive health and wellbeing tips direct to your inbox? We'll also keep you updated on any local events and campaigns.
Email address
Name
(Required)
First
Last
Date of Birth
(Required)
Month
Month
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2
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12
Day
Day
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Year
Year
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1920
Do you consent to the Healthy Hounslow team contacting you about your referral via mobile/telephone or voicemail?
(Required)
Yes
No
Mobile/Telephone number
(Required)
Do you consent to the Healthy Hounslow team contacting you about your referral via email?
(Required)
Yes
No
Email address
(Required)
IMPORTANT. You must either allow us to contact you via email or telephone otherwise we won't be able to support you.
Address
(Required)
Street
Town/City
Postcode
