B2RHCS Couch 2 5K Health Coaching
Pre - Application

By completing this form, you will join a waiting list for a fully funded place on our next available course.
We hold courses every 12 weeks and once the deadline for the applications is reached for our next course, you will be contacted by our health coach, Steve Grantham.
Places are limited, so if you are unsuccessful or unable to make the dates offered, you will be considered for our next course.
Please complete all questions below - Your referral may not be processed until all the necessary information has been received.
If you need help completing this form, please email enquiry@b2rhealthcoachingservices.co.uk giving your name and telephone number - a staff member will then call you within a few days to help complete the form.
Please note that to register for this service, you should be:
  • Aged over 18 years
  • Be a patient of the Ashford PCN Group
  • Be able to take part in a group activity 
  • Be looking to make a lifestyle change to improve mental and physical health
  • You understand this will require to take part in a physical activity
If you suffer from any of the following, you should refer to your medical practitioner before registering for this service:
  • Aortic Stenosis
  • Resting Tachycardia >100bpm
  • Systolic blood pressure (BP) >180mmHG
  • Uncontrolled Arrhythmias (Irregular heart rhythm)
  • Uncontrolled Diabetes
  • Unstable Angina
  • Unstable or acute heart failure
  • Any other condition which might be exacerbated by exercise
Our next course will start 13th January and continue for 10 weeks.
* indicates required

We use your phone number to call and text you about appointment information. We use your email address to contact you about your referral and also to seek feedback while you are engaging with our service or shortly afterwards. Health Coaches may also use your email address to contact you about appointments and send you resources. Please make sure you have written it accurately on this form. People have told us that emails from us sometimes go into their spam folders. Please check these folders in your email account to ensure that you haven’t missed correspondence from us. Information you share with us is confidential between you, our service and your GP. The only time we will break this confidentiality is if we are concerned that there is a serious risk of harm to you or someone else. We store information on our IT system. This is confidential, and cannot be accessed by anyone outside of our service. We do share anonymous information with NHS England and other statutory bodies that monitor our performance. This information may include details on the number of people we see, what type of treatment they receive, or if they recovered. This does not include your name, address, contact details etc. Upon commencement of the course B2R Health Coaching is required to collect personal data including but not limited to weight, height, BMI, blood pressure, smoking habits, alcohol consumption, PHQ9 (Depression Screening), GADS7 (Anxiety Screening) and General Practice Physical Activity Questionnaire scores. To allow B2R Health Coaching to track your progress and health the information collected above will again be collected upon completion of your course. Your data may be anonymised and used to provide statistical data regarding the effectiveness of this treatment for studies and improvement of delivery. By signing this document, I consent to: • B2R Health Coaching collecting this information and sharing it with my registered GP Surgery so that they may update my file, • B2R Health coaching contacting my emergency contact in the event of an emergency, • Passing on any health information to the relevant health authority in the event of an emergency.

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