Northern Ireland Chest Heart & Stroke
Referral to ‘Taking Control’

Our ‘Taking Control’ Self Management Programme is a weekly workshop of 2.5 hours over 6 weeks. It is suitable for people with long term health conditions and aims to give them the skills and confidence to manage their condition more effectively.

If you would like to refer a patient, please fill in the form below. We also accept self-referrals. Click here for more details about the programme.

Details of patient:

First Name

Surname

Gender

Date of Birth (DDMMYY without /)

Address Line 1

Address Line 2

City

County

Postcode

Contact Phone Number

Contact Email Address

Health Condition

Details of person referring:

Title

First Name

Surname

Contact Phone Number

Contact Email Address

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