Self Referral Form

Self Referral Form

Please note that we only take referrals in Exeter for adults aged 18+.
Name:*

First NameLast Name
Preferred Name (if different from above):

First NameLast Name
Date of Birth:*

DayMonthYear
Gender:*
Preferred Pronouns:
Address (by providing your address, we may contact you by letter if required):*

Address Line 1

Address Line 2

CityCounty

Postcode
Phone Number (by providing your phone number, you agree to receive texts from us):*

Area CodePhone Number
Email (please provide if available):
Contact Preferences (tick all that apply):*

Phone / TextVoicemailWhatsAppEmailLetter
Consent

We need your consent in order to work with you.
I give my consent for you to contact me.*

Yes - please proceed with referral (we cannot work with you without this consent)
Working with Us
What do you hope to gain through working with us (tick as many as apply):*

Discover opportunities on how to live and feel betterImprove wellbeingInformation about available resources and opportunitiesIntroduction to groups (social, support, activity etc)Support to access education / training / learn new skillsSupport to meet new people / get to know the community betterThe chance to talk to someone and be listened toSupport to become more physically active?Other
You may wish to give further details here:
Eligibility Criteria
Please acknowledge you meet the eligibility criteria to proceed:*

Live in ExeterNot already registered with Wellbeing ExeterReady to engage with a Community Connector
Disclaimer: Wellbeing Exeter reserves the right to limit, suspend or refuse services to anyone based on our professional opinion, and at our discretion at any time, and without giving details or reasons.
www.wellbeingexeter.org.uk
Should be Empty:

Self Referral Form

Consent

Working with Us

Eligibility Criteria