Working Well Norfolk - Healthcare Professional Referral Form

Please fill in the form below ensuring that all the “Required” boxes are complete. This information is needed for us to assess your eligibility for the programme.

Section 1 – Eligibility and background

Section 2 – About the referrer

Referring organisation:(Required)

Referrer's telephone number:(Required)

Referrer's email:(Required)

Section 3 – About the participant being referred

Participant's date of birth:(Required)

Participant's national insurance number (if known):

Participant's telephone number:

Participant's gender(Required)

Statement to read by the Referrer to the Participant being referred

Your Personal Data

Seetec is committed to data security and the lawful, fair and transparent processing of personal data. We will process the personal data you provide only for the purposes of joining the Working Well Norfolk Programme and to provide the referrer with updates on your progress.

Your data will be retained only for as long as necessary to complete this process, and if you decide that you no longer wish to join the programme or your referral is not approved, your data will be deleted from our systems within 30 days of notification.

We may retain anonymised data (data which cannot be associated with you) for statistical and reporting purposes.

For further information on how Seetec processes personal data, please see our privacy policy.

By making this referral the referrer confirms that they have explained the purposes for the data sharing by reading the above statement to the Participant being referred and that the Participant has given their consent for data to be shared between Seetec Pluss and the Referrer for the purposes of joining and progressing on the Working Well Norfolk Programme.