SILS referral form

Solihull Lifestyle Service Referral Form

To make a referral to the Solihull Integrated Lifestyle Service, please complete the form below.

Client details will be emailed to Gateway Family Services via secure NHS email, and the person you have referred will be contacted directly. For more information, call 0800 599 9880 and ask about the Solihull Integrated Lifestyle Service.

Click here to download a blank PDF version of this referral form.

(If client is BMI 25+ please detail other risk factors below)
ideally in cm
ideally in kg
Eg: reasons for referral, relevant medical history, other risk factors to support BMI 25+ referral
If you are referring yourself, put your own name here
Eg name of GP surgery or other agency. If you are referring yourself, leave this blank
We will contact this number if we have further questions about the referral
We need this for our records, but we will only use it if we need to contact you for more information.
If you would like to receive a copy of the client details you have submitted, enter the email address to which you would like them sent. (Please note, we cannot guarantee the copy will be received by your email server.)