Telephone health coaching Tasmania’s free telephone health coaching program Do you need support and advice to manage or help prevent type 2 diabetes, heart disease or stroke? Join the free telephone coaching program now to become actively involved in looking after your own health. The COACH program® is an evidence-based, award-winning coaching prevention program for people with chronic disease or at high risk of chronic disease. Delivered by ºÚÁÏÍø in Tasmania, The COACH Program® is a free service available to people over the age of 18, who have: type 2 diabetes pre-diabetes a high risk of diabetes, including women who have had gestational diabetes coronary heart disease (heart attack, stent or heart surgery) a high risk of heart disease a high risk of stroke To join, please fill in the consent form below, and we will be in contact with you to start you on your COACH journey. Share the program Download the program resources to help spread the word about Tasmania’s free telephone health coaching service. Brochure Posters Email banner Social media tiles Download all resources (zip file) Coach Program Consent – Tasmania "*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Your DetailsFirst name*Surname*Phone number*Email* Street name and number*Suburb*Postcode*Date of birth*Do you have one of these?Please selectA high risk of developing Type 2 diabetesPre-diabetesType 2 diabetesPrevious Gestational DiabetesHeart disease (heart attack, stent or heart surgery)High risk of developing coronary heart diseaseHigh risk of strokeIf you indicated "high risk of developing coronary heart disease/stroke" above. Please choose your risk factor/s: I am at high risk of coronary heart disease because of (select at least o): I have had a TIA or mini-stroke I have been told by my GP that I am at high risk of heart disease I have high blood pressure I have high cholesterol I have diabetes I smoke I am not sure, but I would still like to talk to a health professional about whether I would benefit from participating in The COACH Program Where did you hear about The COACH Program?Please selectGPMy own researchDiabetes educatorOther health professional/service1800PREVENT (Type 2 diabetes)RHH Neurology ClinicConsent To get started, we need to get your consent to use and disclose some of your personal and medical information. You should know: We will only use this information as part of The COACH Program®; We will keep your information secure and confidential; By signing this form, you authorise ºÚÁÏÍø and The COACH Program®; to: Send copies of correspondence provided to you as part of The COACH Program®, to your treating doctor(s) or health provider(s), unless you advise otherwise; Contact your GP practice to obtain your health record information Authorise your pathology provider to release any test results associated with diabetes/heart disease/stroke including HbA1c and/or OGTT and/or fasting glucose; ACR, eGFR, Creatinine, Total Cholesterol, Triglycerides, HDL, LDL. These tests will have been undertaken within a twelve-month period prior to the consent date and up to two years following; and Use de-identified data (that is, statistical data with no personal information identifying you) from The COACH Program® for evaluation and reporting purposes, including for purposes of academic discussion. Acknowledgement I have read, understood, and consent to the above collection, use and disclosure of my personal information.Family doctor/GP name*General practice name*General practice phone number*Consent box* I give my consent to the above Your feedback is valuable to us as we work to improve our services to you. If you have any questions, compliments, complaints, or general feedback about The COACH Program, please complete this form.
