Health Lifestyle Action - Self Referral Form

Thank you for your request to join the Health, Lifestyle, Action Programme.

Please ensure all required fields are completed before submitting the form.

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IMPORTANT NOTICE: The information collected in this questionnaire is strictly confidential, and for use by Programme staff only. Together with information collected at each of the sessions, it will be used to guide your treatment. In some cases, anonymised data may also be submitted to our public health partners for research purposes. Please discuss any concerns you may have regarding this information with the clinic staff at any time. If you do not wish for your data to be used in this way, then please let the team know at the time of booking and we can discharge you from the programme.

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