Refer someone

Please note that your patient is only eligible to use this service if they live, work or have a GP in Stoke-On-Trent and:

Have a moderate or severe mental health illness
Are currently pregnant
Live with or are the partner or family member of a pregnant woman who is accessing our service.

If you would like to register a patient on a phone call, please contact us directly on 0808 169 1869

Patient title*

Patient First Name*

Patient Last Name*

Patient Phone*

Patient Email

Patient Address Line 1

Patient Address Post Code

Patient Date of Birth*

Gender*

Ethnicity*

What is their first language?*

Do they need the support of a translator?

Yes

What is the name of the GP practice which you are referring from?*

Are they a care leaver?

Yes

A care leaver is an adult who has spent time living in the care system, away from their family

Do they consider themselves to be a carer?

Yes

Do they consider themselves to have a disability?

Yes

Are they Pregnant?

Yes

Do they have a partner who is pregnant or live with someone who is pregnant?

Yes

Do they have any mental health illnesses at the moment?

Yes

Please contact them via:*

Please confirm that you have read and agree with both the informed consent information and the weight management health declaration (if engaging with weight management services). You may withdraw your consent at any time. You can read both on our Data Protection Policy page*

You data is submitted in accordance with our Privacy Policy and will not be used other than for helping you access the programme

Service provided by:

Smoke Free Pregnancy
Smoke Free Family
Smoke Free Life
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Reed Wellbeing Limited. Company Number: 09449184. Registered in the UK.
Registered Office: Academy Court, 94 Chancery Lane, London WC2A 1DT

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