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 Stop Smoking Support Havering, Barking and Dagenham by Healthy Lifestyles - London Borough of Barking and Dagenham I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "Havering Residents / Barking and Dagenham Residents / People that work for Barking and Dagenham council / age 12+ Registered with GP in Barking and Dagenham / Registered with GP in Havering" 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 What are the reasons for this referral? Finances Mental health Pregnant Living with someone who is pregnant COPD Living with someone with COPD Waiting for surgery Smoker This field is required. Should the service provider be aware of any additional needs? Blind/partially blind Memory problem Hearing loss Housebound Does not speak English Poor mobility Learning and communication needs Physical disability Frail Other: Please share some brief details regarding this referral What is your occupation or the occupation of the person you are referring? Do you or does the person you are referring have a long term health condition? Is which one? None COPD Cancer Heart Disease Epilepsy Angina Asthma High Blood Pressure Diabetes Type 1 & 2 Hypertension Arthritis HIV / Aids Other: This field is required. How did you hear about this service? Bubbles for bus stop advert (Havering) Street advert train station Facebook X ( Twitter) GP Pharmacy Friend/Family members Online newsletter newspapers/magazine posters in community hubs 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
