The Burford Centre CIC – Initial Treatment & Referral Questionnaire

The Burford Centre CIC – Initial Treatment & Referral Questionnaire

Answer the questions about your referral, needs, and safety screening so the team can arrange your assessment.
1. Referral route
Referral route
Referrer full name

First NameLast Name
Referrer role / job title
Organisation
Relationship to client
Referrer phone

Area CodePhone Number
Referrer email
example@example.com
Secure correspondence address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
2. Client or Self Referral details
Full legal name

First NameMiddle NameLast Name
Preferred name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pronouns
Phone number

Area CodePhone Number
Email address
example@example.com
Address and postcode

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred communication method

Other
Best time to contact
Preferred language
Interpreter or access needs
If the client is a minor or needs representation, please complete the following details: guardian or representative name, relationship, phone, email, authority, and emergency contact name, relationship, and phone.
Guardian or representative and emergency contact details
3. Reason for referral
Please note: The centre does not provide medical diagnosis. This section helps us understand your referral needs and current situation.
Primary reason for referral
Additional reasons or conditions

Other
Diagnosis or working diagnosis
Affected area or areas
Onset date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Severity of current issue

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Impact on everyday life
Treatment or support received to date
Current clinician or service involvement
Any restrictions or precautions we should know about
4. Requested support
Primary service requested
Other interests or support areas

Other
Desired frequency
Preferred days, times, and any transport or accessibility needs
5. Physical Activity Readiness & Safety Screening
Physical Activity Readiness & Safety Screening
This is not an official licensed PAR-Q+. Red-flag symptoms such as active chest pain, severe sudden breathlessness, or new stroke symptoms require emergency help immediately and this form must not be submitted for those situations. There is no automatic clearance based on answers; clinician review is required before exercise.
Has a doctor ever advised you to limit exercise or only exercise under supervision?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Do you have chest pain at rest or during physical activity?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Do you experience dizziness or fainting?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Do you have heart disease or high blood pressure?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Do you experience breathlessness beyond your usual level?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Have you had a stroke, transient ischaemic attack (TIA), or a neurological condition affecting you?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Do you have any bone, joint, or spine issue made worse by physical activity?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Have you had recent surgery, hospitalisation, or a fracture?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Is pregnancy or the postpartum period relevant for you at this time?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Do you have diabetes or have you had episodes of low blood sugar?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Do you have seizures?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Do you have falls or balance problems?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
Is there any other condition that may make physical activity unsafe for you?
If yes or unsure, please give details
Is medical clearance or advice available for this issue?
6. Health background
Current diagnoses

Other
Date of surgery, if applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Allergies and intolerances
Disability, communication or sensory requirements
Mobility aids used
Current healthcare professionals involved in your care
Do you take any regular medication?
Medication names and doses (optional)
Upload a relevant clinician letter, prescription or medication list (PDF, JPG or PNG only)

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7. Goals and expectations
Main goals

Other
Activities you want to get back to

Other
What would success look like in 3 months?
Areas you want to improve

Other
Personal requirements or preferences
Barriers that may affect your progress

Other
Do you consent to us contacting you to arrange your assessment?
8. Consent and privacy
Please confirm that the information provided is accurate to the best of your knowledge. This service is not an emergency service, treatment is not guaranteed, and medical clearance may be required before support can begin.
I acknowledge that sensitive health information will be processed for referral and assessment purposes, and I have read the privacy notice.
Privacy notice link: [insert privacy notice URL here]
I consent to relevant information being shared with the named referring professional.
I would like to receive marketing updates from the Centre.
Typed name

First NameMiddle NameLast Name
Capacity
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

The Burford Centre CIC – Initial Treatment & Referral Questionnaire

1. Referral route

2. Client or Self Referral details

3. Reason for referral

4. Requested support

5. Physical Activity Readiness & Safety Screening

6. Health background

7. Goals and expectations

8. Consent and privacy