Mid-Sussex | Referring a Patient
Title
Please Select
Mr
Mrs
Miss
Ms
Mx
Sir
Dame
Dr
Cllr
Lady
Lord
First name
*
Last name
*
Date of birth
*
/
Day
/
Month
Year
Gender
*
Please Select
Agender
Female
Gender fluid
Gender non-conforming
Intersex
Male
Non-binary
Other
Prefer not to say
Transgender - female to male
Transgender - male to female
Ethnicity
Please Select
White: British or Mixed British
White: Irish
White: Any other white background
Black or Black British: African
Black or Black British: Caribbean
Black or Black British: Any other Black background
Asian or Asian British: Bangladeshi
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Any other Asian background
Mixed: White and Asian
Mixed: White and Black African
Mixed: White and Black Caribbean
Mixed: Any other mixed background
Other Ethnic Groups: Chinese
Any Other Ethnic Group
Prefer not to say
Does the patient speak English?
*
Yes
No
Is the patient on the Learning Disability Register?
*
Yes
No
Is the patient on the SMI Register?
*
Yes
No
Phone number
*
Additional phone number
Where can we leave a voicemail?
*
Please Select
Both numbers
Telephone number
Mobile number
Neither
Do we have permission to send the patient text reminders?
*
Please Select
Yes
No
Email address
Address line 1
*
Address line 2
*
Address line 3
Address line 4
Address line 5
Post code
*
Referrer name
*
Referrer organisation
*
Please Select
Mid Sussex Wellbeing
TellJo
Dietitian
Referrer email address
*
Main referral reason
*
Please Select
Weight management
Pre Diabetes management
Mental Health Support
General Health and Wellbeing
Smoking Cessation
Lifestyle advice
Diabetes Support
Physical Activity support
Nutrition Advice
Coping with Stress
Secondary referral reason
Please Select
Weight Management
Pre Diabetes Management
Mental Health Support
General Health and Wellbeing
Smoking Cessation
Lifestyle Advice
Diabetes Support
Physical Activity Support
Nutrition Advice
Coping with Stress
Please tick any that apply. Is the patient:
*
A carer
A young person leaving care
Someone who's first language isn't English
An individual with learning difficulties or autism
An individuals with Serious Mental Illness (SMI)
None of these apply
Referral Source
Default Funder Name
Notes (max 200 characters)
0/200
Does the patient consent to their information being shared with Xyla so they can participate in the programme?
*
Yes
Submit
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