Welcome to SWASFT

Staying Well Service referral form

Confidentiality statement

Your Staying Well Service is committed to providing the highest standards in all our interactions with you. We aim to offer you a first class service and hold dignity and privacy of all our employees accessing our service at the heart of all we do.

Your Staying Well Service is confidential and we protect any information about your individual circumstances that you choose to share with us.

We keep computer based records of all the information you provide. This enables us to offer you a professional service and to ensure you receive appropriate advice and support. All personal and sensitive data is processed according to the requirements of the Data Protection Act 1998.

In rare instances if a member of the Staying Well Service has good reason to believe that you or others may be at risk of serious harm, we may share information with other relevant parties. In such circumstances we would aim to discuss this with you first.

Your Staying Well Service may collect routine statistical information which is later anonymised for audit and evaluation purposes.

Should you wish to explore further any queries arising from this statement please contact us and we will be happy to discuss.

Staff detail

Physiotherapy

If your referral relates to physio please complete the following information. Please note that the entitlement to physio is one referral per 12 months on a rolling basis:

Referral details

Self assessment - REFERRER to complete

About you (if details different from above)