The Weight Management on Referral contract is managed by the Gloucestershire Healthy Lifestyles Service. Slimming World will remain the sole provider, but all referrals should be sent to theHealthy Lifestyles Servicein the first instance for further assessment and relevant baseline data capture.
OVRVIEW OF REFERRAL PATHWAY
COMPLETE THE REFERRAL FORM
Explain that following the referral, patients will receive communication from the Healthy Lifestyle Service, where they will have the opportunity to discuss whether they are ready to take up this offer, and to find out more about the service, before they contact Slimming World. Please ensure that all sections of the referral form are completed.
EMAILTHE REFERRAL FORM TO HEALTHY LIFESTYLE SERVICE
If you are using nhs.net accounts – this system is secure and you can send this completed form without encryption to
If an NHS.net account is available within your practice/organisation, it must not be a general account used by staff who would not need to see the referral forms.
Inclusion Criteria
- Age 18+
- BMI >30
- BMI > 28 with co – morbidities
- BMI >27.5kg/m2 of Asian Origin with or without co-morbidities
- Motivated to lose weight
- Able to attend weekly support meetings for 12 weeks
- Ready to commit to the programme with full understanding of what to expect and what will be expected of them
- Not attended a previous referral (e.g. Slimming World or a similar commercial weight management programme) in previous 6 months
- Has an eating disorder
- Has an underlying medical cause of obesity that would benefit from more intensive clinical management
- Has self-funded sessions with a weight management provider in the 3 months prior to referral.
Weight Management on Referral
(Slimming World) Referral form
Referrer Consent(to be completed by GP/Referrer)Referrer’s details
(e.g. Surgery or referring organisation name & address) / Click here to enter text. /
Patient’s Name: / Click here to enter text. /
Patient’s DOB: / Click here to enter text. / Patient’s ethnicity: / Click here to enter text. /
Patient’s height / Click here to enter text. / Patient’s weight / Click here to enter text. /
Please note that patient’s height and weight must be completed before sending referral form
Patient’s Gender: / Male ☐ Female ☐ Transgender ☐
Patient’s Address: / Click here to enter text. /
Patient’s contact details: / Telephone number: Click here to enter text.
Email address: Click here to enter text.
Please indicate all relevant conditions which apply to your patient
1 / Cardiovascular disease or risk e.g. Coronary heart disease; Stroke / TIA; Raised blood cholesterol or triglycerides; / ☐ / 2 / Hypertension / ☐ /
3 / Diabetes or Insulin resistance / impaired glucose tolerance (IGT) / ☐ / 4 / Respiratory condition e.g. sleep apnoea, asthma, chronic obstructive pulmonary disease / ☐ /
5 / Personal or family of history of breast, endometrial or colon cancer / ☐ / 6 / Musculoskeletal condition e.g. Osteoarthritis, chronic back pain. / ☐ /
7 / Mental health condition e.g. depression, anxiety / ☐ / 8 / Awaiting surgery / ☐ /
9 / Other: please specify below / ☐ /
I recommend for the above person to be referred to the Weight Management on Referral pathway to receive onward signposting and support. I confirm that I have assessed this person, and to my knowledge there is no medical reason why he/she should not be referred .
Please indicate any additional comments, issues or special considerations that will need to be considered by Slimming World
I confirm that I have discussed this referral, and the reasoning for it, with the person named above.
Comments / Known issues / conditions: / Click here to enter text. /
Important information: Please complete referrers details and date of referral / GP / Referrers Name: Click here to enter text.
Date of Referral: Click here to enter text.
Patient Consent (to be agreed by Patient)
I consent to being referred to the Weight Management on Referral scheme. The nature and purpose of which has been explained by my GP/referrer.
I consent to the release of relevant personal information about myself to the Gloucestershire Healthy Lifestyles Service / Slimming World. I understand this information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controllers are my referring GP practice / referrer. I understand that I have (i) the right to change my mind about being referred to the service and to withdraw consent and (ii) right of access to my information -☐ (please tick box)
I give permission for my GP / referrer to be kept informed of my progress -☐ (please tick box)
Additional guidance for referrers sending this electronic form by email
If you are using nhs.net accounts – this system is secure and you can send this completed form without encryption to
If anNHS.net account is available within your practice/organisation, it must not be a general account used by staff who would not need to see the referral forms.
If referrers do not haveNHS.net accounts, they need to ensure all personal and sensitive personal information is contained within the attachment which should be encrypted to theNHS Encryption Standard whichis AES 256. Encryption software such as WinZip (paid for) and7Zip (free) enable encryption to be selected to this level.
In line with Information Governance, please send the password in a separate method of communication – e.g. by telephone. Additionally, if you require more information or support, please contact the Healthy Lifestyles Service on 0800 122 3788.
Thank you for your co-operation
V3 -May 2017