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Online referral form EPP

 

Please read the consent conditions below before you submit your request

To take part in a self-management course, basic information about you such as your name, address, telephone number, type of long term condition, GP practice, date of birth, ethnicity, where you heard about the programme, if you’re a wheelchair user and carer status will be recorded.

This information will be stored on a national secure database and will never be shared with any individual or organisation without your explicit consent and is being kept for the purposes of evaluation of the course and to enable the EPP team to contact you.

You will also be consenting to the following:

  • To be contacted by telephone or text reminder prior to the course starting and for a voice message to be left.
  • Your anonymised feedback about the programme will be kept on record for evaluation purposes.

If you change your mind you can withdraw your consent at any time. This information will automatically be deleted from the database following a period of six years.

By clicking 'submit your request' button above you are consenting to the above information being held as described.

 

Rydym yn croesawu gohebiaeth a galwadau ffôn yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. Mae’r dudalen hon ar gael yn Gymraeg drwy bwyso’r botwm ar y dde ar frig y dudalen.

We welcome correspondence and telephone calls in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. This page is available in Welsh by clicking ‘Cymraeg’ at the top right of this page.