Community Health Improvement Referral Form

NHS Number:
Client’s Name:
Address:
Post code:
Tel. No:
Email:
DOB:
Male Female (Please circle) / Referring Agency /Practice:
Name of referrer:

Profession:

Your Tel No:
Your Email:

I recommend this client for (tick)… checkcriteria on next page

[ ] Social Prescribing Service (Community Health Trainer)

[ ] Exercise on Referral (Long Term Condition management)

[ ] Staying Steady (Falls Prevention programme)

Q. Is this referral post NHS Health Check? Yes [ ]No [ ]
Q. Have you checked criteria on next page? Yes [ ] No [ ]
N.B. Please mention there is a small cost to the client for the Exercise on Referral
We will contact the client directly to agree an appointment
To be signed by GP/Practice Nurse or other referring agent
I can confirm that I have discussed this referral with the patient and have their permission to pass on relevant health information about them
Signed: …………………………………………… Date: ………………………………………
GP Surgery :
GP Name:
Primary reason for referral :
Long Term medical condition (if applicable):
Please attach health summary printout as appropriate
Additional comments:
Last B/P?
Send this form to:
Please state required service
Mail:Health Resource Centre, Adelaide Terrace, Benwell, Newcastle upon Tyne, NE4 8BE
Fax: 0191 226 0802 (Social Prescribing Service –Community Health Trainer)
Fax: 0191 272 4244 (Exercise on Referral & Staying Steady)
Email:
If you are referring a client with limited English, unfortunately we cannot provide aninterpreter however clients can bring a family member or friend who speaks English.

Referral Guidelines

  1. Social Prescribing Service (Community Health Trainer Service) (City wide)

Community Health Trainers support individuals to make positive lifestyle changes. As an outreach service, health trainers offer a personalised, client centred approach. They give 1:1 short term support around emotional wellbeing and confidence, healthy eating and physical activity. This includes enabling access to services on offer within the community and addressing issues of social isolation.

The team are all qualified to Level 3 or above in a discipline aligned to social prescribing work.They are also trained as intermediate smoking cessation advisors.

Health Trainers act as a bridging service to a variety of citywide organisations that can help with other health related issues such as mental health and alcohol dependency.

This service focuses on individuals living in areas of disadvantage. Self-referrals are accepted for this service.

Inclusion criteria

•Individual is keen to try this service

•Can commit / is willing to attend regular, weekly appointments within the community

•Is 18 years or over

•Independently mobile, or mobility support in place, to access sessions within the community

•Able to consent and to follow an agreed plan, or has the support in place to do so

Exclusion criteria

•Presents any known risk of violence/aggression

•At the end stages of a terminal illness

•Has a severe and enduring mental illness or short term memory loss, requiring specific expertise.

Contact: Tel: 0191 273 8889 Fax: 0191 226 0802

  1. Exercise on Referral (inner west of the city) The Health Resource Centre, Benwell

Referrals for this scheme are accepted from any health professional.

Inclusion criteria:

  • Long term medical condition/s (CVD, Diabetes, COPD, OA, RA etc)
  • Preparing for or recovering from surgery e.g. joint replacement
  • At risk or fear of falling (and / or Osteoporosis)

Exclusion Criteria: The following patients should NOT be referred:

  • Unstable angina
  • Resting SBP>180mmHg or DBP>100mgHg
  • Uncontrolled tachycardia
  • Unstable diabetes
  • Unable to follow instruction
  • Only Weight Management (Social Prescribing Team instead)

Contact:Service Tel: 0191 2724244

Fax: 0191 2724248N.B. There is a (subsidised) charge to the patient for this service.

  1. Staying Steady (community fall’s prevention) City wide

Referral criteria: (one or more of the following):

  • History of falls (either injurious or non injurious fall)
  • Fear of falling
  • Feeling unstable or unbalanced
  • Low bone density and / or family history of osteoporotic fracture.

Any patients that have not been through the Falls Service will be assessed by a specialist physiotherapist and referred on as appropriate. Self referrals are accepted for this service.

Contact: Tel: 0191 272 4244 or Fax: 0191 272 4248

HealthWORKS NewcastleNewcastlePublic Health

A Health Partnership

Revised November 2017