Online Staying Well Self Referral Form

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This referral form is not to be used by professionals.

The Staying Well team can work with any adult in Calderdale from 18 years and over to access social activities and health and well-being related services in the community.

Consent to share your personal data

I understand that by ticking this box I am giving my consent for my contact details provided in this form to be shared with a Calderdale Staying Well Worker who will contact me about my referral and may send me further information about services and activities relevant to me.

I understand that information I provide will be stored on a secure database for no more than 3 years and will only be accessible by the Staying Well Team, and that I can withdraw my consent at any time.

Required

Staying Well is a service of Calderdale Council. The data is centrally managed by North Halifax Partnership on behalf of Calderdale Council and the service is delivered in partnership with Halifax Opportunities Trust and Hebden Bridge Community Association. Your referral information may be shared with Staying Well staff working from any of these organisations.

North Halifax Partnership Ltd is registered as a ‘data controller’ with the Information Commissioner’s Office under the Data Protection Act. You can find out more about the Data Protection Act, and your legal rights at https://ico.org.uk

North Halifax Partnership, Calderdale Council, Halifax Opportunities Trust and Hebden Bridge Community Association will only use your personal information for the purpose which we have stated when we collect that information, and we will not collect unnecessary information about you, or keep your information for longer than it is needed. We will ensure your personal data is held securely and is not seen by anyone who should not see it.

Please click here https://northhalifaxpartnership.org/privacy-notice/ to read our Privacy Notice on the NHP website.

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