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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.
Referrer's name/Parent's or Guardian's name
(Required)
Referrer's Name/Parent's or Guardian's name (if referring a child under 16)
Referring Organisation
Not required if Parent or Guardian
Referrer's/Parent's or Guardian's email
(Required)
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 ≥ 91th centile (scoring equal to 91 or above)
Aged 5-17 - BMI is < 91st centile
Aged 18+ BMI is ≥ 30 (score equal to 30 over above BMI of 30)
Aged 18+ BMI is < 91st BMI is ≥ 27.5 if of Black African, African-Caribbean or Asian origin (score equal to 27.5 over above BMI of 27.5)
Aged 18+ BMI is < 30
Aged 18+ BMI is < 27.5 even if of Black African, African-Caribbean or Asian origin
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/
Email
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.
I'm ready to commit
I can't commit right now
Don't worry! We have lots of information and guidance to help support your health and wellbeing. Click our website to take a look: https://healthyhounslow.co.uk/
Name
(Required)
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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
