One You Haringey Referral Form This form can be used for self-referrals into our service or referrals by health professionals and community organisations. Name First name Family name/surname Address Street Address Address Line 2 City Postcode Please confirm you are a Haringey resident. (Your address is in the borough of Haringey or you are registered with a Haringey GP) Yes No Do you require a translator? Yes No Please state which language. Email Enter Email Confirm Email Contact numberPlease state if pregnant Yes No Date of birth Day Month Year Your ethnicitySelect your answerWhite BritishWhite otherBlack/Black British AfricanBlack/Black British AfricanMixed White and Black CaribbeanAsian/Asian British BangladeshiWhite IrishAsian/Asian British Other BackgroundMixed White and AsianAsian/Asian British IndianMixed Other BackgroundBlack/Black British OtherUnknownAny Other Ethnic GroupPrefer not to sayHealth conditions Serious mental illness (impairs your daily life and usually receiving medication) Other mental health conditions Long term condition (a condition that cannot be cured) for example diabetes, asthma, arthritis, epilepsy, chronic fatigue, and high blood pressure No health conditions Prefer not to say Please select all that applyYour genderSelect your answerFemaleMaleNon-binaryOtherNot knownPrefer not to sayPlease select your sexual preferenceSelect your answerHeterosexual/straightGay or LesbianBisexualOtherNot surePrefer not to sayFor demographic purposesPlease select your occupationSelect your answerIntermediate – hospitality/retailRoutine/manualProfessional/managerialRetiredUnpaid carer/homemakerUnemployedSick/disabled/unable to workFull time studentPrefer not to sayFor demographic purposesPlease indicate which service you would like Be smoke free – Quit for good Drink less Lose weight Move more – free exercise classes Health check-mid life MOT Where did you hear about One You Haringey? OptionalGPOther health professionalSocial mediaCommunity eventHealth Champion/AmbassadorFriend/family memberOtherPoster/leafletNot sureTree of Eternal Life – Healthy Hearts projectFor self-referrals onlyConsent I agree and consent to the referral and to sharing this information with Haringey GP Federation and I understand that my information will be stored on an electronic database. (Personal information can be removed on request) Or I am referring somebody to the service and they agree to the above statement regarding sharing their information.
