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.

Please monitor your junk/spam email folder so you don't miss anything from us.

About you

Title

First name

Last name

Date of birth

Ethnicity

Gender

Sexual Orientation

Religion

Relationship status

Are you ex-British Armed Forces?

Your contact details

Work email address

Personal email address

Phone number

Can a voicemail be left on this number

Home address line 1 (please do not provide your work address)

Home address line 2

City/town/village

County

Postcode

Your job role

What is your job role?

Which service do you work in?

Which organisation do you work for?

Your health history

GP surgery

GP surgery address

Do you have any long-term heath conditions such as diabetes, a heart condition or stroke, chronic pain or respiratory conditions?

Please tell us briefly about your long-term health conditions:

Do you have any disabilities?

Please tick all that are relevant to you:

Hearing

Sight

Speech

Learning disability

Physical disability

Other

Do not wish to say

Not known

Have you ever received treatment or support from mental health services?

Please tell us why you are referring yourself to the Here For Each Other Wellbeing Service

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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