Self Referral Form

This referral form is for you to refer yourself for 1:1 Health & Wellbeing Coaching.

Please note that coaching is only available to staff working within Primary Care Networks and Care Provider Services within Dorset.

Is Health & Wellbeing Coaching for me?

Health & Wellbeing Coaching may be suitable if you are struggling with stress, burnout or want to support your own resilience and/or physical wellbeing. 

Coaching is about collaborating and working together, so that you can discover your inner strengths and resources which will help you to navigate life problems more effectively.  Coaching can be seen as a protected space which is solution-focused and practical, helping you reach your desired goals and make positive changes in your life.

Coaching is not structured training, e.g. classroom learning, and should not be used as a replacement for counselling, therapy and or mental health support.

If you are unsure, please see Our Offering page for further information about Health & Wellbeing Coaching.

I need emergency help

We are not a crisis service and are not the best service for you if you are very distressed, despairing, or suicidal. If you require urgent mental health support, please contact Dorset’s 24/7 Connection helpline on 0800 652 0190, or visit our Access Mental Health Dorset page for further support options.

I don’t want anyone to know

We take confidentiality very seriously. The form is fully secure and all details you provide will be stored on our confidential system.

By completing this form, you agree to these terms and to be contacted via any available method.

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About you
Your contact details
Your job role
Your health history
Please tick all that are relevant to you:

Thank you for completing this form. Please press 'submit' to send your referral through to us. We will be in contact with an appointment offer as soon as possible. Please monitor your junk/spam email folder so you don't miss anything from us.


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