Healthcare Professional Referral Request

Which scheme are you wishing to refer to?

Active Lives
Eligibility Questions:

Is your patient a Cheshire East resident? I need to check
Yes No Unfortunately your patient is not eligible for this programme as they must be a resident in Cheshire East.
To find out more about what we offer at Everybody Health & Leisure visit our website

Is your patient aged 18 years and over?
Yes No Unfortunately your patient is not eligible for this programme as it is for adults aged 18 years and over.
To find out more about what we offer at Everybody Health & Leisure visit our website

Is your patient inactive and participating in less than 30 minutes of moderate physical activity per week?
Yes No Well done on keeping active, unfortunately your patient is not eligible for this programme as it is for those who are inactive and participating in less than 30 minutes of moderate physical activity per week.
To find out more about what we offer at Everybody Health & Leisure visit our website

Does your patient live in Crewe or Macclesfield?
Yes No

Has your patient been diagnosed with either diabetes (medicated), hypertension (medicated), diagnosed as pre-diabetic, or are they overweight with a BMI of 30+?
Yes No Unfortunately your patient is not eligible for this programme as it is only for inactive adults with either hypertension (medicated) or diabetes (medicated).
To find out more about what we offer at Everybody Health & Leisure visit our website

Programme description

Active Lives is a 12-week programme, providing tailored support to people who want to become physically active.

The programme is delivered by coaches who are fully qualified in prescribing exercise, including for people with medical conditions. Who provide guidance, support and motivation towards being more active and improving health.

The programme is for adults who are inactive, participating in less than 30 minutes of physical activity per week and have either diabetes (medicated), hypertension (medicated), diagnosed as pre-diabetic, or overweight with a BMI of 30+.

Active Lives can be accessed in the community, online or in a leisure facility.

Eligibility Criteria

Cheshire East resident
18 years and over
Inactive; participating in less than 30 minutes of physical activity per week
With either diabetes (medicated), hypertension (medicated), diagnosed as pre-diabetic, or overweight with a BMI of 30+
Motivated to be physically active
A non-member of Everybody Health & Leisure or Bollington Health & Leisure in the last 12 months

Exclusion Criteria

A recent significant change in a resting ECG, recent myocardial infarction or other acute cardiac event.
Symptomatic severe aortic stenosis
Acute pulmonary embolus or pulmonary infarction
Acute myocarditis or pericarditis
Suspected or known dissecting aneurysm
Resting Systolic Blood Pressure 180mmHg / Diastolic Blood Pressure 110mmHg
Uncontrolled / unstable angina
Acute uncontrolled psychiatric illness
Unstable or acute heart failure
New or uncontrolled arrhythmias
Other rapidly progressing terminal illness

Programme description

Active Lives is a 12-week programme, providing tailored support to people who want to become physically active.

Active Lives can be accessed in the community, online or in a leisure facility.

Eligibility Criteria

Cheshire East resident
18 years and over
Inactive; participating in less than 30 minutes of physical activity per week
Motivated to be physically active
A non-member of Everybody Health & Leisure or Bollington Health & Leisure in the last 12 months

Exclusion Criteria

A recent significant change in a resting ECG, recent myocardial infarction or other acute cardiac event
Symptomatic severe aortic stenosis
Acute pulmonary embolus or pulmonary infarction
Acute myocarditis or pericarditis
Suspected or known dissecting aneurysm
Resting Systolic Blood Pressure 180mmHg / Diastolic Blood Pressure 110mmHg
Uncontrolled / unstable angina
Acute uncontrolled psychiatric illness
Unstable or acute heart failure
New or uncontrolled arrhythmias
Other rapidly progressing terminal illness

Stand Strong
Eligibility Questions:

Has your patient been a member of Everybody Health & Leisure or Bollington Health & Leisure in the last 12 months?
Yes No Unfortunately your patient is not eligible for this programme.
To find out more about what we offer at Everybody Health & Leisure visit our website

Is your patient aged 65 years and over?
Yes No This programme is for adults aged 65 years and over only.
To find out more about what we offer at Everybody Health & Leisure visit our website

Does your patient have one or more of the following? *
• Had 2 or more falls • Presented with an acute fall within the last 12 months • Have difficulty walking or with balance * Please note - Further screening will be done at a clinic prior to starting the programme to check eligibility. Yes No Unfortunately your patient is not eligible for this programme.
To find out more about what we offer at Everybody Health & Leisure visit our website

Programme description

Stand Strong is a 26-week evidence-based Otago exercise programme, consisting of strength and balance exercise classes, prescribed home exercises and education on reducing falls risk factors.

This programme will help participants increase their confidence, remain independent and in their own home for longer.

Stand Strong can be accessed in the community or online.

Eligibility Criteria

A non-member of Everybody Health & Leisure or Bollington Health & Leisure in the last 12 months
Cheshire East resident
Aged 65 years and over and had one or more of the following:
- Had 2 or more falls
- Presented with an acute fall within the last 12 months
- Have difficulty walking or with balance

Participants will then be invited to a clinic for further eligibility testing.

Exclusion Criteria

The following are not permitted:

Housebound
Unable to self-care
Unable to stand and exercise without assistance

Re-shape
Eligibility Questions:

Is your patient a Cheshire East resident? I need to check
Yes No Unfortunately your patient is not eligible for this programme.
To find out more about what we offer at Everybody Health & Leisure visit our website

Is your patient aged 18 years and over?
Yes No Unfortunately your patient is not eligible for this programme.
To find out more about what we offer at Everybody Health & Leisure visit our website

Is your patient’s BMI 25+ or 23+ for people of ethnic minority?
To check their eligibility visit the NHS BMI Calculator Yes No Unfortunately your patient is not eligible for this programme.
To find out more about what we offer at Everybody Health & Leisure visit our website

Programme description

Re-Shape is a 12-week adult weight management programme, consisting of diet, exercise and behaviour change.

Re-shape covers new healthy eating habits, portion control, food labels, good sleep hygiene and much more.

There are 4 options to select from to access this programme, whether thats attending in-person classes, online, Second Nature digital app or Slimming World.

Eligibility Criteria

Has not been on the programme twice in the last 12 months (or 3 times in the last three years)
Cheshire East resident
Aged 18 years and over
Have a BMI of 25+ or 23+ ethnic minorities

Exclusion Criteria

Has been on the programme twice in the last 12 months (or 3 times in the last three years)

Let's Get Movin'
Eligibility Questions:

Is the child aged between 4 and 17 years of age?
Yes No This programme is for children between the age of 4 - 17.
To find out more about what we offer at Everybody Health & Leisure visit our website

Has the child identified as having excess weight?
Yes No Unfortunately your patient is not eligible for this programme.
To find out more about what we offer at Everybody Health & Leisure visit our website

Programme description

Let’s Get Movin’ is a 12-week, family-focussed, physical activity and healthy eating programme, supporting families in making healthier lifestyle and dietary choices.

Eligibility Criteria

Has not been on the programme twice in the last 12 months (or 3 times in the last three years)
Cheshire East resident
Aged 4- 17 years
Identified as having excess weight

Exclusion Criteria

Has been on the programme twice in the last 12 months (or 3 times in the last three years)

Referral Details

Questions marked with * are mandatory fields

First Name *

Surname *

Address *

Town *

County

Postcode *

Contact numbers (please provide at least one) *

Mobile number

Landline number

Gender *

Date of Birth *

Ethnicity *

Employment Status *

Disability Status *
Unknown
No disability
Cognitive impairment (such as autistic spectrum disorder or resulting from a head injury)
Specific learning disability (such as dyslexia)
Long standing illness or health condition (such as cancer, HIV, diabetes or epilepsy)
General learning disability (such as Downs Syndrome)
Mental health condition (such as depression or schizophrenia)
Deaf or serious hearing impairment
Blind or serious visual impairment
Prefer not to say
Other type of disability

Emergency Contact:

Name

Telephone Number

Relationship To Patient

Reason For Referral *

Referring Organisation *

First Name of Referrer *

Last Name of Referrer *

Phone Number of Referrer *

Email Address of Referrer *

Profession of Referrer *

Comments

How did you hear about this service? *

Scheme consent

Please tick if you agree to the following statement

I agree for my information to be shared between One You Cheshire East (Cheshire East Council Commissioner of the Service), Everybody Health & Leisure and Bollington Health and Leisure for monitoring and evaluation purposes. I understand that my details will be stored on a secure database system in an appropriate confidential manner. I agree to be contacted by letter, email, telephone, and SMS text message. You can view our terms and conditions here. I Agree

I agree for my information to be shared between One You Cheshire East (Cheshire East Council Commissioner of the service) and Everybody Health & Leisure (and where relevant our partners such as Second Nature and Slimming World) for monitoring and evaluation purposes. I understand that my details will be stored on a secure database system in an appropriate confidential manner. I agree to be contacted by letter, email, telephone, and SMS text message. You can view our terms and conditions here. I Agree

I agree for my information to be shared between One You Cheshire East (Cheshire East Council Commissioner of the Service) and Everybody Health & Leisure for monitoring and evaluation purposes. I understand that my details will be stored on a secure database system in an appropriate confidential manner. I agree to be contacted by letter, email, telephone, and SMS text message. You can view our terms and conditions here. I Agree

Healthcare Professional Referral Request

Active LivesEligibility Questions:

Programme description

Eligibility Criteria

Exclusion Criteria

Programme description

Eligibility Criteria

Exclusion Criteria

Stand StrongEligibility Questions:

Programme description

Eligibility Criteria

Exclusion Criteria

Re-shapeEligibility Questions:

Programme description

Eligibility Criteria

Exclusion Criteria

Let's Get Movin'Eligibility Questions:

Programme description

Eligibility Criteria

Exclusion Criteria

Referral Details

Scheme consent

Active Lives
Eligibility Questions:

Stand Strong
Eligibility Questions:

Re-shape
Eligibility Questions:

Let's Get Movin'
Eligibility Questions: