This website requires JavaScript to function. Please enable JavaScript or use a web browser that supports JavaScript.

Text Size: Contrast:

Barnsley Premier Leisure Online Referral Form

Barnsley Health Referral Scheme

12-week Health Referral Scheme is run by Barnsley Premier Leisure and aims to help reduce health risks through promoting physical activity as a long term and sustainable lifestyle change.

Inclusion Criteria

You are 16 years of age or above.
You participate in less than 30 minutes of moderate physical activity per week.
Your medical condition is mild to moderate and stable.
You can exercise independently (or with Carer support).

Fields marked with an * are required fields.

Details of the person being referred

First name *

Surname *

Address *

Town *

County *

Postcode *

Please provide either a mobile number or a landline number *

Mobile phone number

Landline phone number

Email *

Date of birth *

Gender *

Ethnicity

GP Practices

Patient preferred centre to attend

Medical conditions (tick all that apply)

Alzheimer's disease

Angiogram

Angioplasty / Stent

Aortic valve replacement (AVR)

Arrhythmias

Asthma (Controlled)

At risk of falls

Atrial fibrillation

Back Pain

CABG

Cancer

COPD (Mild-Moderate)

COVID-19

CVD/CHD

Dementia

Diabetes (Type 1)

Diabetes (Type 2)

ETT / ECG

Fibromyalgia

Heart failure

Hypercholesterolaemia : >6.5mmmols

Hypertension >140/90 BUT <180/100 controlled under BP Plan

ICD / Pacemaker fitted

Joint Replacement

Learning Disabilities

Long COVID

LV function - good

LV function - moderate

LV function - poor

Mild Depression

Mild-moderate Anxiety/Stress

Multiple Sclerosis (stable)

Musculoskeletal (pain/injury)

Neurological

NSTEMI

Obese (30-39.9)

Osteoarthritis

Osteoporosis

Overweight (25-29.9)

Parkinson's Disease (stable)

Post surgery rehabilitation

Pre Surgery

Rheumatoid arthritis

Severely Obese (40+)

Stable Angina

STEMI

Stroke/TIA

Undergone a percutaneous coronary intervention (PCI)

Other

Medication & Dosage

Reason for referral *

By completing this form, you agree to BPL processing and storing your personal data for the purpose of your participation in the BPL Health referral program, I understand the information provided is essential to my application and I consent to this information being stored securely in accordance with the General Data Protection Regulations (GDPR – 2018).Personal data will only be used by BPL and Healthcare partners and it will not be shared with any other third parties , we will keep data safe and will never share it without permission. I agree to be contacted by letter, email, telephone, and SMS text message. Find more about BPL Privacy Policy at bpl.org.uk/privacy

Some of the form fields are required. Please check you have filled out all required fields.

Tick if you want to download a copy of the form as a PDF file.

Tick the box to confirm you're not a robot.

Cancel

The security credentials shown here are held by ReferAll, as the host of this form. For details about your activity provider's own security standards, please contact them directly.

Certification Number 26393

The verification and validation of Refer-all Limited and digicert.com has been done in accordance with the Extended Validation guidelines laid out by the CA/Browser Forum. SSL certificates protect data in transit between users and the websites they are connected to.