Health Services and Charities - Enrol

As a referral partner, please confirm that you have received consent from the individual to share their details. Please note this is a requirement under GDPR.

Yes No

Referee (the person you are referring onto the course)

Age group

Are they attending the course due to Long Covid?

Yes No

If yes, are they 12+ weeks post-onset of Covid-19 symptoms? Symptoms can include: on-going breathlessness (not requiring further investigation), anxiety, fatigue, Disordered Breathing Pattern, Hyperventilation Syndrome.

Yes No

Please state any long-term respiratory condition (e.g., Asthma, COPD):

Do they have other significant comorbidities? Please state:

Do they suffer from (please tick all that apply):

Delivery address for resource packs

Any special delivery instructions?

Please state any days or blocks of times (e.g. morning, afternoon, evening) they are NOT available to attend a course

Is there any other information you/they wish to communicate?

Payment Information

They are able to pay the course fee of £45 They need to apply for a bursary The individual lives in Kingston Upon Thames The individual lives in Richmond Upon Thames

Please explain why it is important to you to go on this course

Are you able to contribute financially at all to the course? If so, how much can you manage?

Please state what benefits you are currently on (just the main ones) OR if you are on a low level of income

Please upload any photos of your benefit award letters (maximum of 2 uploads)

Your Privacy

We will always store your personal details securely. We'll use them to provide the service that you have requested, and communicate with you in the way(s) that you have agreed to. Your data may also be used for analysis purposes, to help us provide the best service possible. For full details see our Privacy Policy

Health Services and Charities – Enrol

Referral Organisation Information

Referee (the person you are referring onto the course)

Delivery

Payment

Your Privacy

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