Wellness Works Referral Form

Please use this form to refer yourself or someone else to the Wellness Works programme. We support people with health-related barriers to work through our Keyworker Programme and by connecting residents to their local Health Hub for community-based activities and support.

If you are making this referral on behalf of someone else, please ensure you have obtained their consent first, and please give us your details as well as theirs, when asked.

This activity is managed by TSL Kirklees and is part of Healthy Working Life, a joint programme of the West Yorkshire Combined Authority and NHS West Yorkshire Integrated Care Board.

I am making a referral for...

Myself

Someone else

Referrer Information

Your Name

Organisation Type or Relationship

Organisation Name

Phone Number

Email Address

Do you have consent from the individual to share their information with us?

Yes, I have consent

No, I don't have consent

About You

Please complete the form below. If you don't have your NHS Number and National Insurance Number you can still submit the referral but we do need this information so please have both ready when we contact you about your referral.

Title

Forename

Surname

National Insurance Number

NHS NumberFind Your NHS Number

Date of Birth

Post Code

Please Select The Postal Address

Where in Kirklees do you Live?

How would you like to be contacted?

Telephone Number

Email Address

In order to process your referral, we need to be able to contact you. If you provide an email address, we will contact you by email. This could be from any of our Wellness Works Delivery Partners. If you provide a mobile number, we will call you or text you. You can change these contact preferences at any time - but we must have at least one means of contacting you.

About the Individual being Referred

Please complete the form below. If you don't have the NHS Number or National Insurance Number you can still submit the referral but we do need this information and will gather it from the individual when we contact them.

Title

Forename

Surname

National Insurance Number

NHS Number

Date of Birth

Post Code

Please Select The Postal Address

Where in Kirklees do they Live?

How would they like to be contacted?

Telephone Number

Email Address

In order to process this referral, we need to be able to contact the individual. If you provide an email address, we will contact them by email. This could be from any of our Wellness Works Delivery Partners. If you provide a mobile number, we will call them or text them. They can change these contact preferences at any time - but we must have at least one means of contacting them. By submitting this referral you confirm you have obtained consent for us to contact the individual as you have indicated above.

Please indicate any concerns, risks or relevant issues we should be aware of.

e.g. safeguarding concerns

Reason for Referral

Please provide a brief summary of the reason you are making this referral.

What level of support is required?

Key Worker
One-to-one support keyworker support with help to build confidence

Key Worker and Volunteering Support
One to one keyworker support with help to build confidence and find a volunteering placement

Connect with Health Hub
Access activities, groups and wellbeing support

Not sure
Need a Discussion about Options

Are there any language or access barriers that we need to consider?

e.g. wheelchair user, non-English speaker etc

How did you hear about Wellness Works?

A TSL Kirklees Managed Project

Wellness Works Referral Form v3