Level 2 Weight Management Self-Referral Form

1. Help with my Weight

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Self-referral guidance
  • Please visit the Betsi Cadwaladr University Health Board Help with my Weight webpage to see available services before completing this form.
  • This form can be used to self-refer to Second Nature or KindEating programmes. If you are interested in attending a FIT Dragons programme please visit Wrexham AFC website to apply.
  • To complete this form you will need your height, weight and BMI. Click here to check your BMI 
  • We can only accept self-referrals for adults with BMI 30-45kg/m2 (or 27.5-42.5kg/m2 if from Asian, Black, Chinese or Middle Eastern ethnic group). If your BMI is below this range please visit Healthy Weight Healthy You for self-directed support.
  • Please note weight loss medications are not available through self-referral.
  • If your BMI is above this range referral by a health professional will ensure we have the necessary information to provide the most appropriate support. Please consult your GP.
  • This form is for self-referral only. If you wish to refer someone else, please ask your health professional to refer by WPRS or  BCU.DieteticsAdultWeightMgt@wales.nhs.uk
 

1. First name *

 

2. Surname *

 

3. Address and Postcode *

 

4. Are you registered with a GP in North Wales? *

 

5. What is the name and address of your GP? *