Referral Form - Smoke Free Liverpool

I would like to*

Schedule a call
Book an appointment
Make a professional referral (secure)
Contact you about something else

This is a secure form. The details you provide will be sent to our secure nhs.net email address

Client name*

First Last

Name*

First Last

Address*

Address line 1 Address line 2 City Post code

Date of birth*

Gender*

Female
Male
Other

Ethnicity*

NHS number

Email address*

Telephone number (preferred)*

Telephone number (alternative)

Employment status*

Which of the following best describes their field of work?*

Unknown
Routine & Manual
Intermediate
Managerial & Professional

"Routine & Manual" : electrician, fitter, gardener, inspector, plumber, printer, train driver, tool maker, bar staff, caretaker, catering assistant, cleaner, farm worker, HGV driver, labourer, machine operative, messenger, packer, porter, postal worker, receptionist, sales assistant, security guard, sewing machinist, van driver, waiter/waitress.

"Intermediate" : call centre agent, clerical worker, nursery auxiliary, office clerk, secretary.

"Managerial & Professional" : accountant, artist, civil/mechanical engineer, medical practitioner, musician, nurse, police officer (sergeant or above), physiotherapist, scientist, social worker, software engineer, solicitor, teacher, welfare officer. Those usually responsible for planning, organising and co-ordinating work for finance.

Preferred time(s) to call to arrange the next step*

Morning
Afternoon
Evening

May we leave a message?*

Yes
No

Preferred time(s) for an appointment*

Morning
Afternoon
Evening
Weekdays
Weekends

Preferred type(s) of consultation call*

Telephone call
Online video call

Does the client need to stop smoking in preparation for an operation?*

Yes
No
Unknown

Has the client been diagnosed with a mental health condition?*

Yes
No
Unknown

Please select all that apply

Anxiety
Depression
Bipolar
Personality Disorders
Psychosis
Other Mental Health Condition
Stress

Is the client pregnant?*

Yes
No
Unknown

Due date*

Does the client suffer from diabetes?*

Yes, type 1
Yes, type 2
No
Unknown

Has the client been diagnosed with any of the following long term health conditions?

Preferred clinic location (if known)

Has the client consented to receiving information from the practice/pharmacy on stopping smoking and/or the services available?*

Yes
No

Name of referring Hospital / Practice / Pharmacy / Other*

Ward (if applicable)

Name of GP/health professional/pharmacist/other*

Are you pregnant?

Yes
No

GP Practice*

Do you have any medical conditions?

Do you have any additional needs we should be aware of?

Other

Do you suffer with any stress/anxiety or Mental Health conditions (please select all that apply)

None
Anxiety
Depression
Bipolar
Personality Disorders
Psychosis
Other Mental Health Condition
Stress

What best describes your ethnicity?*

What best describes your employment status?*

Which of the following best describes your field of work?*

Routine & Manual
Intermediate
Managerial & Professional

"Routine & Manual" : electrician, fitter, gardener, inspector, plumber, printer, train driver, tool maker, bar staff, caretaker, catering assistant, cleaner, farm worker, HGV driver, labourer, machine operative, messenger, packer, porter, postal worker, receptionist, sales assistant, security guard, sewing machinist, van driver, waiter/waitress.

"Intermediate" : call centre agent, clerical worker, nursery auxiliary, office clerk, secretary.

"Managerial & Professional" : accountant, artist, civil/mechanical engineer, medical practitioner, musician, nurse, police officer (sergeant or above), physiotherapist, scientist, social worker, software engineer, solicitor, teacher, welfare officer. Those usually responsible for planning, organising and co-ordinating work for finance.

Consent*

Consent Provided

By entering your details, you are agreeing for us (Solutions4health) to process your data and to contact you to discuss treatment options in relation to stopping smoking. Should you continue with the support offered we may share this data where necessary with other health professionals such as your GP or specialist services if it contributes towards your stop smoking support. The information we collect and process will be used to help us meet the contractual obligations as set down by the local health service commissioners in accordance with the service we are providing. You can request to view, amend or delete your data at any time by contacting us here.