1 System 4 Health

Disclaimer: This is not an NHS Service.

Before we can continue, we need to ask you the following consent questions:

I consent to treatment/participation and to be contacted by the service.

I agree for ABL Health to collect my information in line with General Data Protection Regulation (UK GDPR), Data Protection Act 2018 (DPA). KCC Privacy Notice is available on request.

I agree to share my personal and health information with relevant professionals in support of my treatment, including One You Kent's partner organisations when appropriate.

Notes

I agree to act in line with the NHS zero-tolerance policy to aggression and violence.

I understand I can withdraw my consent at any time, unless required by law.

Weight Management - Free 12-week programme offering support from nutrition and exercise specialists. The programme focuses on behaviour change and uses motivational interviewing techniques to support individuals in making sustainable lifestyle improvements.

Stop Smoking - Free 12-week programme of personalised behavioural support from trained advisors, with access to nicotine replacement therapy and/or medication tailored to individuals.

Healthy Lifestyle - Free service tailored to individual needs, offering regular support to help individuals take the first step towards a healthier lifestyle and supporting them to boost wellbeing, improve sleep, eat well, move more or drink less alcohol. Up to seven sessions of personalised behavioural support from trained advisors, to introduce lifestyle changes and signpost to further support as needed.

Referral Details

Are you completing this referral for yourself, or on behalf of somebody else?

Type of referral

Other Type of Referral

Interested in *

Name of referee *

Organisation working for *

Referrer email *

Referrer job role

Referrer department

Referrer contact number

Team working for

Manager Email

Manager contact number

Consent Details

Do you give consent to data recording? *

Yes No

Consent to contact *

Yes No

User Information

Title

Gender

Forename *

Surname *

DOB *

Age

Are You A Health Professional

Address Information

Search Any Part Of Address

Postcode *

Address line 1 *

Address line 2

Address line 3

Address line 4

Address line 5

Borough

Address type

Contact Information

Please provide at least one contact method: Mobile Number, Telephone Number, or Email Address. Once you enter one, the other fields will no longer be required.

Mobile *

Email *

Practice telephone *

Happy to be contacted via *

Status Information

Socio economic status / occupation

Sexual orientation

Ethnicity *

Religion

Additional Information

Pregnant *

Yes No

Breast feeding *

Yes No

How did you hear about the service

Next of kin

Next of kin relationship

Next of kin telephone

Do you have any medical conditions?

Are You Taking Any Prescribed Medication?

Practice name

Does the patient require reasonable adjustments?

Reasonable adjustments

Notes

BMI Calculation

Height feet

Height inches

Height meter

Weight stone

Weight pounds

Weight kg

Bmi *

Clinical Exclusions Check

Are you pregnant?

Are you breastfeeding or have stopped breastfeeding in the last 6 months?

Are you currently taking weight loss medication?

Motivation & Readiness

Are you ready to engage with support? *

Yes No

Do you want to engage with the service?

Yes No

Self Referral

Referral Form

Referral Details

Consent Details

User Information

Address Information

Contact Information

Status Information

Additional Information

BMI Calculation

BMI Calculation

Clinical Exclusions Check

Motivation & Readiness

Appointment Booking Confirmation

Appointment Booking Confirmation

Accessibility

Choose an Appointment

Appointment Booking Confirmation

Appointment Request Summary

Confirmation Message

Message