This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Health & Wellbeing Coaching by GP Connect Who is this referral for? I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "Open to patients of the following surgeries only; Stoke Aldermoor Barley Lea - Woodway Medical Practice - Phoenix Family Care - Windmill Surgery - Parkhouse Surgery - Patient to self-refer" Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. What are the reasons for this referral? Improving Sleep Becoming More Active Improving Diet Weight Management Perimenopause & Menopause PMS / PMDD Living with ADHD Coping with Anxiety Lowering Stress Levels Improving Relationships Behaviour Change Increase Motivation WorkWell Other: This field is required. Please share some brief details regarding this referral Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
