Team Member Referral Form

This referral form is to refer a colleague for 1:1 Health & Wellbeing Coaching that is available to staff working within Primary Care Networks and Care Provider Services within Dorset only.

Please note that your colleague must be aware and consent to the referral being made on their behalf.

Is Health & Wellbeing Coaching suitable for your colleague?

Health & Wellbeing Coaching may be suitable for someone struggling with stress, burnout or want to support with their resilience and/or physical wellbeing.

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

Do you think they may need emergency help?

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

They 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, yourself and colleague 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.

Your details

Your name

Your phone number

Your email address

Your job role

Which service do you work in?

Which organisation do you work for?

Please confirm that the team member your want to refer is aware and consents to the referral being made?

Your colleagues’ details

Title

First name

Last name

Date of birth

Ethnicity

Gender

Sexual Orientation

Religion

Relationship status

Are they ex-British Armed Forces?

Does your colleague have any disabilities?

Please tick all that are relevant:

Hearing

Sight

Speech

Learning disability

Physical disability

Other

Do not wish to say

Not known

Has your colleague ever received treatment or support for mental health services?

Please tell us why you are referring your colleague to the Here For Each Other Wellbeing Service today:

Your colleagues contact details

Work email address

Personal email address

Phone number

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

Home address 2

City/Town/Village

County

Postcode

Your colleagues job details

What is their job role?

Which service do they work in?

Which organisation do they work for?

Thank you for completing the form. Please press submit to send your referral to the Here For Each Other staff wellbeing service. We will be in contact with your colleague as soon as possible. Please ask them to monitor their junk/spam email folder so they do not miss anything from us.

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