MCR - Active

About you (person making the referral)

Organisation ^*

About your client

Prefix ^*
First Name ^*
Middle Names
Surname ^*
Preferred Name (Known as)
Home Address ^*
Town ^*
Postcode ^*
Date of Birth (dd/mm/yyyy)^*
Telephone ^*
Mobile
Email
Gender ^*
NHS Number

Nominate a contact (who can we contact about this referral if not you)

Contact's relationship to client
Contact's first name
Contact's surname
Contacts's mobile number
Contact's email

GP details

GP's Practice

GP's Name

Support

Does your client have any access needs?
We cannot guarantee that we can refer or signpost clients to sessions which have these access features but we will do our best to do so, and to improve our sessions to be more inclusive.

Autistic Spectrum Disorders (ASD)
Hearing impairment
Hearing loop
Learning disability
Physical disability
Visual impairment
Difficulty with physical co-ordination
Interpreter (English is a second language)
Mental health issues
Speech impairment
Step-free access
EasyRead format
Prefer not to answer
Other

Does your client have any other requirements or preferences when it comes to attending physical activity sessions?

Women Only
Men Only
Sessions actively inclusive of LGBTQIA+ people
Sessions specific to LGBTQIA+ people
Sessions which are condition/impairment specific (e.g. for Autistic people, for visually impaired people, seated sessions)
Culturally appropriate or specific sessions (e.g. for Muslim women)
Other

Written communication in second language

Written communication in another language (not English)

Will someone attend the appointments or physical activity sessions with your client? (For example, a relative, friend, personal assistant or other professional)?

YesNoUndecided/Unsure

How did your client hear about the service?

Is there any further information that you wish to provide that will assist us in dealing with your client?

Referrer Consent

I refer this patient in accordance with the guidelines of the scheme, which I have received, read and understood. If I become aware of their condition/s changing in a way that would affect the client’s ability to exercise I will inform the scheme as soon as reasonably possible.