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Self-referral form - part 1

Please answer these questions which will give you an idea of the suitability of our community weight loss services for you and the commitment we require from clients who sign up for our support.

I am able to attend at least 8 sessions from a 12 session weight loss management programme

I am happy to be weighed at the beginning and end of the programme

I have my own important reasons for wanting to lose weight, and not just because someone else thinks I should

I am committed to make all efforts that I reasonably can to improve my eating habits and food choices

I am committed to make all efforts that I reasonably can to increase my levels of activity

I am confident that this is the right time to make the changes in my life

I understand that if I do not attend appointments or cancel them at short notice the service may discharge me

This page was last updated on: Wednesday 11th November 2015