Core Sport Referral

Agree

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. This referral form is open for clinical referral.

If you are a GP, or HCA referring someone on the SMI Register - please use the EMIS autopopulate referral form (Primary Care Mental Health Alliance Partnership) and send via nhs email to josie.jennings@nhs.net.

If you are a GP and referring someone who is not on the SMI register please continue to use this form to provide sign off to engage with Core Sports via the Wellbeing Network provision.

Please note: If you are not a GP/ Doctor, but a primary or secondary care clinician, you are able to initiate referral via this form submission. However, please be aware sign off from a doctor will be required for the member to be able to engage with our sessions. Therefore, please contact the GP requesting this to be sent to our Core Sport referrals coordinator -cc.ing Josie.Jennings@nhs.net in all correspondance with the doctor to ensure a collaborative approach for sign off to engage with health activities safely.

Client details:

Name*

First NameLast Name

NHS Number*

Priority Care Team*

Other - 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 *

Any specific information:

Client address*

Street Address

Street Address Line 2

City

PostCode

GP & Surgery name*

GP practice email*

example@example.com

Consent to liaise with GP / HCA directly

YesNo

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

Learning disability that requires any reasonable adjustmentsComplex or multiple needsHomelessness/ Housing support needsSubstance use needsBehaviour/ impulse control/ anger management issuesRequires support to attend i.e. escorted as part of care and support planCurrently an inpatient or recently dischargedSpecific health or mobility issues

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.

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.

All timetabled activities (High impact)Low impact only

Please specify in there is any reason this person can't participate and provide further information.

Date sent for sign off

Date

Referrer details

Name*

First NameLast Name

Organisation*

Email*

example@example.com

Telephone*

Primary careSecondary care

Most recent Health Check date*

Date

YesNo

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 or health issues 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