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Level 2 Weight Management Self-Referral Form
1.
Help with my Weight
Self-referral guidance
Please visit the Betsi Cadwaladr University Health Board
Help with my Weight webpage
to see available services before completing this form.
This form can be used to self-refer to Second Nature or KindEating programmes. If you are interested in attending a FIT Dragons programme please visit
Wrexham AFC
website to apply.
To complete this form you will need your height, weight and BMI. Click
here to check your BMI
We can only accept self-referrals for adults with BMI 30-45kg/m2 (or 27.5-42.5kg/m2 if from Asian, Black, Chinese or Middle Eastern ethnic group). If your BMI is below this range please visit
Healthy Weight Healthy You
for self-directed support.
Please note weight loss medications are not available through self-referral.
If your BMI is above this range referral by a health professional will ensure we have the necessary information to provide the most appropriate support. Please consult your GP.
This form is for self-referral only. If you wish to refer someone else, please ask your health professional to refer by WPRS (Primary Care) or CITO (Secondary Care) to Weight Management.
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1.
Question 1.
First name
Required
- Required.
*
2.
Question 2.
Surname
Required
- Required.
*
3.
Question 3.
Address and Postcode
Required
- Required.
*
4.
Question 4.
Are you registered with a GP in North Wales?
Required
- Required.
Yes
No
*
5.
Question 5.
What is the name and address of your GP?
Required
- Required.
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