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 Enable Learning Disabilities Weight Management Service by LD Adult Weight Management - Enable 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 "● Aged 18 years old and over ● A mild or moderate learning disability ● Resident of, or registered with a General Practitioner in, Bexley, Bromley or Greenwich ● Able to attend a programme either alone or supported by a carer or support worker ● BMI ≥30kg/m2 or BMI≥27.5kg/m2 if from minority ethnic groups (calculate BMI here) Exclusion Criteria ● Under 18 years old ● Pregnant ● Have a history of an eating disorder ● Anyone who does not meet the eligibility criteria set out above" 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 NHS number Ethnicity SelectEnglish, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White backgroundWhite and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic backgroundIndian Pakistani Bangladeshi Chinese Any other Asian backgroundAfrican Caribbean Any other Black, African or Caribbean backgroundArab Any other ethnic groupPrefer not to say Gender SelectFemale Male Transgender female Transgender male Non-binary Intersex Not specified Not known Other Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. Weight (kilograms/ stone) Height (metres) BMI (Kg/M2) Date measured Parent/Carer Full Name Are you attending the programme with the service user? Parent/Carer Home Address Parent/Carer Email Address Parent/Carer Telephone Number Some medications may affect the service user’s ability to exercise and their response to exercise. Please list all medications, or attach a list of medications currently being prescribed. Include further details if necessary: Special Requirements (e.g. transports needs, literacy issues, learning disabilities): How would you like to be contacted? Email Text Phone Contact my carer first This field is required. Consent to contact? Yes No This field is required. 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
