Self Referral

Did you know that some GP practices now have a dedicated Health & Wellbeing services that can provide support and signposting for non-medical matters? For example: help in the community, finances, housing and personalised lifestyle support, to help patients to increase activity levels, improve eating habits and maintain the long-term changes they need to improve their health and wellbeing.

If you believe that yourself or someone you know could be eligible or this service, please fill out the form below. *must be registered at one of the following practices:

- South Leistershire Medical Group

- Billesdon Surgery

If you are referring on behalf of someone else, please fill out sections 1 & 3.

If you are self referring, please fill out sections 2 & 3.

* Required Field

Self Referral Form

Section 1

Please Complete This Section If You Are Referring On Behalf Of Someone Else

If you are self referring - please go to section 2 on the next page.

Section 2

Please Complete This Section If You Are Self Referring

If you are referring on behalf on someone else fill out section 1.

Section 3

Reason For This Referral

Please answer all questions.