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Colleague Wellbeing Referral Form

If you feel that you require confidential advice and wellbeing support that does not require input from your Host Organisation, please complete the form below.


Please note, if you feel that you require additional support and/or adjustments from your Host Organisation as a result of a medical condition, please speak to your Host Organisation, who will be able to submit a management referral via the Lead Employer.

If you have any further questions please dont hesitate to contact us.

Section 1 - Employee Details


GMC Number 

Date of Birth 

Contact Number 

Email Address 

Home Address (Including Postcode) 

Training Region


Current Status

First Day of Absence


Section 2 - Reason for Referral and Background

Please provide an overview of the requirement for a referral and any additional information that may support this request 

Section 3 - Support

Please provide an outline of the support or treatment that you or the individual may have received or is due to receive to support the referral 


Section 4 - Additional Information

Have any reasonable adjustments already been implemented? If so, what are they and are these working? If not, please advise us of further details regarding this 


What happens after the self-referral? 

Once you have completed this form, it will be shared with our Wellbeing Team who will review the information that you have provided and action accordingly. 

Please note, if you require pregnancy related adjustments you should undertake the pregnancy risk assessment available on the LE website in the first instance. This is available on our COVID page.

If you require COVID related control measures within your role, please ensure that you engage with the COVID risk assessment process. You and your host will need to complete the COVID risk assessment form which can be found on our COVID page.