Core Sport Referral

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Core Sports is an inclusive sports programme for Hackney residents wishing to engage with healthy activities and goal setting to support for their mental health and wellbeing.

If you are a GP please use EMIS autopopulate referral form and send via nhs email to josie.jennings@nhs.net.

If you are a primary or secondary HCA we will still need to contact GP for medical clearance.

Client details:

Name*

First NameLast Name

NHS Number*

Priority Care Team*

Please specify*

Date of birth*

Date

Telephone*

Email*

example@example.com

Ethnicity*

Gender*

If other, please specify

LGBTQIA+*

If yes, please specify

Please include the client primary diagnosis *

Please include the client secondary diagnosis *

Any specific information:

Client address*

Street Address

Street Address Line 2

City

PostCode

GP & Surgery name*

Consent to liaise with GP / HCA directly

Client consent to submit details*

YesNo

We have specific contracts for the following client groups (please select if relevant)*

All referrals are assessed on an individual basis at the manager’s discretion regarding suitability of access.

Each member of the programme will be required to sign up to our Code of Respect and will be asked to fill an individual health questionnaire in order to access our programme.
Unfortunately, we may be unable to accept referrals outside of this remit. All referrals are assessed on an individual basis at the manager’s discretion regarding suitability of access.

Please confirm that to the best of your knowledge if the referred person has any of the following support needs:

Learning disability that requires any reasonable adjustmentsUnder secondary mental health care servicesComplex or multiple needs*HomelessnessSubstance use needsBehaviour/ impulse control/ anger management issuesRequires support to attend i.e. escorted as part of care and support plan*Currently an inpatient or recently discharged*

We may be unable to support persons with multiple or complex needs who may require additional support to engage. The aim of this service is to offer autonomy and agency in engagement to achieve personal health goals.

* Please refer directly to Core Arts Recovery Alliance in which Core Sports will be offered as part of their membership in partnership with ELFT. To refer via this route please visit: www.corearts.co.uk/referrer-register/ or call 020 8533 3500.

I confirm the named person is able to participate safely in:*

High impactLow impact onlyAerobic

Please specify in there is any reason this person can't participate.

Date sent for sign off

Date

Referrer details

Name*

First NameLast Name

Organisation*

Email*

example@example.com

Telephone*

Referral type*

Primary care HCASecondary care HCA

Most recent Health Check date*

Date

SMI Health Check*

YesNo

Are they on the SMI register?*

YesNoDon't know

*SMI register includes diagnosis of schizophrenia, bipolar, psychosis or takes an antipsychotic as part of their prescribed medication (this register is held by/reviewed by GP).

High BMIHigh BPDiabetesOther

Any additional patient details you believe we should be aware of (please refer to additional guidance notes):

Sign off:

I confirm that there are no contra-indications to this person participating in physical exercise

Name*

First NameLast Name

Date*

Date

Many thanks for your referral. You will receive feedback as soon as possible.

My Phone Number

Area CodePhone Number

My Email

example@example.com