Weight Management Self-referral Form - Norfolk County Council

You must complete all fields unless they are marked optional.
Privacy notice
1. Read our privacy notice
  Tick to confirm you've read our privacy notice
Well done on taking this first important step on your healthy weight journey.

Before you can proceed with this referral, you will need to answer the following questions to check that you're eligible for the weight management services available.
Date of birth
1. Date of birth
  For example, 27 08 1990
  
  Day
  
  Month
  
  Year
You must be at least 18 years old to be considered for a weight loss programme

Other options that you may wish to explore to support with your weight loss and other healthy lifestyle areas are:
- Just One Norfolk: Healthy Child Programme Just One Norfolk is a website for information about childhood health in Norfolk
- NHS Better Health: Whether you want to lose weight, get active, or quit smoking, Better Health has lots of free tools and support
- The Children's Health and Wellbeing resources page from Norfolk County Council
1. Do you live in Norfolk?
  
  Yes
  
  No
2. Are you registered with a Norfolk GP (doctor)?
  
  Yes
  
  No
3. As you have stated you do not live in Norfolk and are also not registered with a Norfolk GP, you are not currently eligible.
  
  If you are not registered with a GP, instructions on how to register can be found here.
4. Enter the GP (doctor) surgery address you are registered at
  1. Surgery postcode
    
    Postcode
    
    Address
  4. The surgery address is not on the list (optional)
  5. Address (optional) Cannot read property 'CHA1' of undefined
  7. Customer Address
    
    Address line 1 (optional)
    
    Address line 2 (optional)
    
    Address line 3 (optional)
    
    Town / City (optional)
    
    County (optional)
    
    Postcode (optional)
5. 1. Are you currently pregnant?
    
    Yes
    
    No
  2. Weight-loss programmes are not recommended during pregnancy as they may harm the health of the unborn child.
    Please speak with your midwife or GP about suitable weight-loss options.
    
    You can also visit the Just One Norfolk website for lots of information on weight management during pregnancy.
  3. Have you attended a Norfolk County Council funded weight management programme within the last 12 months?
    
    Yes
    
    No
  4. As you have attended a weight management programme within the last 12 months, you are not currently eligible.
    
    Other options that you may wish to explore to support with your weight loss and other healthy lifestyle areas are:
    
    Norfolk County Council's Ready to Change: Step-by-step advice on creating a health improvement plan
    
    Just One Norfolk: Healthy Child Programme Just One Norfolk is a website for information about childhood health in Norfolk
    
    NHS Digital Weight Management Programme: The NHS Digital Weight Management Programme supports adults living with obesity who also have a diagnosis of diabetes, hypertension, or both, to manage their weight and improve their health
    
    The Healthier You National Diabetes Prevention Programme (NDPP): The NDPP programme is free to anyone as risk of Type 2 diabetes, and is delivered in Norfolk and Waveney
    
    NHS Better Health: Whether you want to lose weight, get active, or quit smoking, Better Health has lots of free tools and support
  5. Do you feel that you are motivated and committed to making changes to lose weight?
    
    Yes
    
    No
  6. As you have stated you do not feel motivated and committed to making changes to lose weight, you are not currently eligible.
    
    Other options that you may wish to explore to support with your weight loss and other healthy lifestyle areas are:
    
    Norfolk County Council's Ready to Change: Step-by-step advice on creating a health improvement plan
    
    Just One Norfolk: Healthy Child Programme Just One Norfolk is a website for information about childhood health in Norfolk
    
    NHS Digital Weight Management Programme: The NHS Digital Weight Management Programme supports adults living with obesity who also have a diagnosis of diabetes, hypertension, or both, to manage their weight and improve their health
    
    The Healthier You National Diabetes Prevention Programme (NDPP): The NDPP programme is free to anyone as risk of Type 2 diabetes, and is delivered in Norfolk and Waveney
    
    NHS Better Health: Whether you want to lose weight, get active, or quit smoking, Better Health has lots of free tools and support
  7. Have you reached this online form in response to a specific group you have seen advertised?
    
    Yes
    
    No
  8. Provide details of this group or a code that relates to it (e.g. location, name of group) (optional)
    You can enter up to 1000 characters
  9. Do you have a physical disability, a learning disability, or a mental health condition?
    
    Yes
    
    No
  10. Provide further information which can help the provider make any possible adjustments e.g. wheelchair user (optional)
    You can enter up to 1000 characters
  11. Do you have any medical conditions that the weight management service needs to be made aware of (e.g. epilepsy)?
    
    Yes
    
    No
  12. Provide further information which can help the provider make any possible adjustments (optional)
  13. How did you find out about the Norfolk County Council funded weight management services?
    
    Through the Ready to Change website
    
    Via my GP or other health professional
    
    Via family or friend
    
    Social media or advertisement
    
    An NHS Health Check
    
    Social prescriber
    
    Protect NoW
    
    Active NoW
    
    Norfolk Wellbeing Service (Talking Therapies)
    
    Other (please specify)
  14. Specify where you found out about the Norfolk County Council weight management services (optional)