Expert Patient Programme (EPP) & Diabetes Type 2 Self-Management Programme (DSMP) Referral Form
Supported Self-Management for people with long-term conditions and carers.
Please fully complete the following information.
PATIENT/CLIENT DETAILS
Surname
*
First Name
*
Telephone number
*
Home Address
*
Email address
Male/Female
*
Date of Birth
*
(dd/mm/yyyy)
NHS No.
(if known)
Access Requirements (e.g. wheelchair access, sight impairment, hard of hearing):
Please tick type of Course:
EPP (any long-term condition)
Diabetes Self-Management Programme (type 2)
Islington Only:
New Beginnings (mental health course)
EPP for Somali-speakers
EPP for Bengali–speakers
Haringey Only:
EPP for Turkish-speakers
Diabetes Self-Management Programme (type 2) for Turkish-speakers
All courses are for anyone who has had their condition for more than 3 months OR Carers
Main Health Condition:
*
Other Health Conditions:
REFERRER DETAILS
Referrer’s Name
*
Job Title
*
Team/Practice/Service
*
Telephone number
*
Email address
*