Move More, Eat Well Referral Form

Move More, Eat Well Referral Form
Move More, Eat Well provides free, home-based exercise and nutrition support to older adults living in St Albans & District. Funded by St Albans Old People’s Trust via the Grace Muriel Legacy Fund, this programme offers eight weeks of support centred around exercise and nutritional advice, followed by up to six-months of tailored telephone follow-up. The programme is aimed towards people who may be frail, less mobile, or have limited access to transport or local activities.

Please use this form to make a referral to the service. You can refer yourself, or someone else can refer you. Remember to click submit once you have completed the form.

To contact the Move More, Eat Well service, email movemoreeatwell@hils-uk.org.

Eligibility

The client must meet the following eligibility criteria
Click here to see a map of St Albans District
Please confirm:
Please confirm:
Please confirm:
Please confirm:
Please confirm:
Please note: The programme is less suitable for those with significant memory loss as the client will be required to remember and follow instructions independently. If the person being referred does have significant memory loss, we may be able to support if a carer is present for all sessions, and can provide support in between sessions. Please contact our team at movemoreeatwell@hils-uk.org if you would like to discuss this further.

Client's details
Name

First NameLast Name
Address line 1
Address line 2
Town
County
Postcode
Phone number (main)
Phone number (other)
Email
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
Ethnicity
GP surgery
GP's name
GP's phone number

Referrer's details
Please tick the box that best describes you today:

Other
Referrer name

First NameLast Name
Role or relationship to client
Organisation
Phone number
Email (we will confirm receipt of this referral to this email address)
example@example.com
How did you hear about HILS?
If you have selected 'other,' please tell us how you heard about HILS. It is extremely helpful to share this information with us, so that we can better reach the people who need our services.
Client consent - please tick to confirm that:

Access details
Keysafe code (if applicable)
Keysafe location (if applicable)
Door entry code (if applicable)
Any other access information (for instance, if the property is hard to find, is up flights of stairs, has limited parking, etc.)
Is there anything that could pose a risk to our staff when delivering? (for instance, others in the household, dogs that don’t like visitors, etc.)

Client support contacts

It is very important that an emergency contact is provided. Where possible please provide a mobile number.
First support contact
Name

First NameLast Name
Phone number
Email
example@example.com
Relationship to client
Please tick where applicable
Second support contact
Name

First NameLast Name
Phone number
Email
example@example.com
Relationship to client
Please tick where applicable

PLEASE PRESS SUBMIT

How will your information be used?

Your personal data will only be used to deliver a safe, caring, and tailored service that meets your individual needs. We will never share your data without your consent unless we believe that you may be in danger or that your wellbeing is at risk. In this case, we would only share the information necessary to help you stay safe and well, and only with the proper authorities (e.g. police, ambulance) and/or your emergency contacts. While it is in our care, your data will be kept securely and only viewed by authorised HILS staff. All team members are trained in how to keep your data safe and your rights as a data subject, we do not use any automated decision-making or data profiling processes – meaning all decisions regarding your service are made by humans.

What are your rights?

HILS comply with the General Data Protection Regulation 2016, meaning that we are committed to keeping your personal data safe and will always respect your rights as a data subject. These rights are:

The right to be informed and to limit data processing – this means that we need to tell you about how we are using your personal data and will only use it in the way we describe above. If we want to use your personal data for anything else, we will always tell you and ask for consent if necessary. You have the right to disagree with the way we process your data and to ask for this to be changed, these requests would be reviewed on a case by case basis.

The right to access, ask for corrections, and to delete personal data – this means you can ask to see all the data that we hold on you, to ask for data to be changed and/or deleted from our records.

The right to data portability – this means that you can request for us to provide you with all the personal data we hold on you in a format that you can take with you (e.g. if you want to take your information to another service provider).

To find out more about your rights and how HILS processes personal data, please see our Privacy Notice on our website at: www.hils-uk.org/privacy-policy. You can also contact us via email on data@hils-uk.org or call 0330 2000 103 and ask for the HILS Data Protection Officer.

Click submit below to complete the form, otherwise we will not receive your referral.
Should be Empty:

Move More, Eat Well Referral Form

Eligibility

Client's details

Referrer's details

Access details

Client wellbeing

Client support contacts

First support contact

Second support contact

Nutritional health