Counterweight - Health Professionals Referral Form

1. Personal Details

You can refer a patient to the programme using the form below, or for more info contact the Healthy Communities team on: 01224 507701 or email: activelifestyles@sportaberdeen.co.uk

Patient Contact Details: *

Forename	*
Preferred name	*
Surname	*
Date of birth	*

Address: *

Address 1	*
Address 2	*
Town	*
Postcode	*
Telephone Number	*
Mobile Number	*
Email address	*

Referrer contact details: *

Name of referrer	*
Job role	*
Contact role	*
Contact email	*

How active is the patient currently? E.g. activity could be walking around the block daily/gardening or housework/attending an exercise class once a week

Reason for referring this patient

Privacy Notice *

	Yes	No
The patient has been informed about the programme and wishes to join an exercise group	The patient has been informed about the programme and wishes to join an exercise group Yes	The patient has been informed about the programme and wishes to join an exercise group No
I understand that the information provided will be held at Sport Aberdeen for the purposes of the patient's participation in the programme	I understand that the information provided will be held at Sport Aberdeen for the purposes of the patient's participation in the programme Yes	I understand that the information provided will be held at Sport Aberdeen for the purposes of the patient's participation in the programme No
I acknowledge the Sport Aberdeen Privacy Notice: https://www.sportaberdeen.co.uk/privacy-policy	I acknowledge the Sport Aberdeen Privacy Notice: https://www.sportaberdeen.co.uk/privacy-policy Yes	I acknowledge the Sport Aberdeen Privacy Notice: https://www.sportaberdeen.co.uk/privacy-policy No