EitC Health and Wellbeing Referral Form

Health and Wellbeing Referral Form

	Yes
The patient agrees for the detail contained on this form to be shared with Everton in the Community
The patient agrees to be contacted by Everton in the Community regarding this referral
The patient has been informed that Everton in the Community will share progress on the programme with the referrer, for continuation of care
The patient has been made aware of the Everton in the Community Privacy Notice

Please select the referral programme from the dropdown menu

Safe and Steady

Everton in the Community’s ‘Safe and steady’ Falls Prevention exercise programme Individuals wishing to be referred to EitC’s Falls Prevention exercise programme will need to fit within the criteria outlined below. Should you have any questions or need further information, please contact: Jonathan.garside@evertonfc.com

Inclusion Criteria:

• Registered with a GP in Knowsley or lives in Knowsley
• Age >55 years old
• Have a fear of falling
• A previous history of falls
• Requiring motivation, supervision, monitoring and assistance when choosing the right type of exercise
• A feeling of instability and having problems with strength and balance
• Able to stand independently with/without a walking aid
• Able to mobilise independently with/without a walking aid.
• Previous history of fractures

Exclusion Criteria:
• Resting systolic blood pressure greater than 180mmHg or diastolic greater than 100mmHg
• Significant drop in blood pressure during exercise - greater than 20mmHg
• Tachycardia - Heart rate >100BPM
• Unstable or acute heart failure
• Uncontrolled atrial or ventricular arrhythmias
• Unstable diabetes
• Uncontrolled angina
• Uncontrolled pain
• Severe visual or vestibular disturbances
• Acute systemic illness
• Unable to maintain seated upright posture
• Impaired cognition and unable to follow exercise programme
• Unable to get out of an armless chair independently or when assisted
• Individuals who place themselves or others at risk
• Not registered with a GP

I have read the above criteria and confirm my referral complies with its stated detail

YesNo

Part 1 - Medical Referral Form

Referrer details

Name of person making referral

Date of referral DD/MM/YYYY

Referrer's contact number

Referrer's email address

GP Practice Name

GP Practice email address

Practice address

Practice postcode

Name of registered GP

Reason for referral

Past medical history

Monitoring equality data is essential in allowing us to understand our local community and to ensure that the services provided to them are appropriate and relevant.

Information provided on this form shall be treated in confidence and used only for monitoring purposes. All reports are anonymised; you are not identifiable in them. You can provide all or some of the equality information and can answer that you prefer not to say. A full Privacy Notice is available from the Data Protection Officer or the EitC website.

Please give details if you have answered 'Yes' to any of the above.

Please give details of any other significant past medical history.

The participant agrees to receiving basic First Aid?

YesNo

Part 2 - Agreement for participation in the Everton Football Club and Activities Programme

This form should be completed in conjunction with the medical referral form.

Name

DOB DD/MM/YYYY

CPN/Care Co-ordinator

Referred by

Existing physical illnesses that may limit participation in activity e.g. asthma, heart, back problems.

Current medication

Involvement in:

Football

Activities

Both

How were you signposted to this programme?

Clockview

Broadoak

Other

Please state

Photo Consent

I give permission for Everton in the Community to capture Images and data to demonstrate the impact of its activities.

I acknowledge Everton in the Community may also share images and data with its partners including the Premier League Charitable Fund, Premier League, and Steve Morgan Foundation. Everton in the Community and its partners may seek to share such images across a variety of their media platforms, such as social (Twitter, Facebook, Instagram), websites and internal communications (newsletters and updates).

Images shared with funding and strategic partners of Everton in the Community will contain no personal information about participants.

If you have any concerns about our use of the Images, now or at some point in the future, please contact us john.bilsborrow@evertonfc.com.

YesNo

To: Mersey Care NHS Trust

Whilst a member of the Everton Football Club and Activities Programme (EFFAP), I agree to fully comply with my care package as agreed in my care plan and understand that:

- If I am under or suspected of being under the influence of non prescribed and/or illicit drugs or alcohol, I will not be allowed to participate in the activities on offer and will be asked to leave by a member of staff.

- A risk assessment for any EFFAP activity will have been completed prior to the activity commencing. Any significant risk(s) will be discussed with me as appropriate. Consideration will be given to the suitability of the activities chosen to ensure that I am not exposed to any foreseeable and unreasonable risk.

- There is no guarantee that the quality of any activity accessed through the EFFAP will meet my expectations.

- I am not required to take part in every activity and I may opt out of any activity at any time.

- I will also be expected to take full responsibility for the care of and security of my personal belongings for the duration of the activity.

- I am responsible for my actions and owe a duty of care to others participating in the EFFAP to not intentionally cause injury or loss.

- Nothing in this Agreement shall exclude Mersey Care NHS Trust’s liability for death or personal injury caused by the negligence of Mersey Care NHS Trust or for any other liability which cannot be excluded or limited under applicable law.

Service user (name if applicable)

Date DD/MM/YYYY

Member of staff (if completing the form on behalf of someone else)

Date DD/MM/YYYY

This form should be signed by the service user and countersigned by a member of staff e.g. CPN, Health Professional, Doctor, Physio etc.

A copy of Everton in the Community's Privacy Notice can be found at https://www.evertonfc.com/content/privacy. If you require further information please contact our Data Protection Officer on 0151 705 9725.

Contact Information

Male	Female
Other	Prefer not say

Arabic	Asian
Black	Chinese
Mixed	White
Prefer not to say	Other

Black/African/Caribbean/Black British - African	Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - Other	Black/African/Caribbean/Black British - (Unspecified)

Mixed/multiple ethnic groups - White and Asian	Mixed/multiple ethnic groups - White and Black African
Mixed/multiple ethnic groups - White and Black Caribbean	Mixed/multiple ethnic groups - Other
Mixed/multiple ethnic groups - (Unspecified)

White - Welsh/English/Scottish/Northern Irish/British	White - Irish
White - Gypsy, Roma or Irish Traveller	White - Eastern European
White - Other	White - (Unspecified)

Hearing impairment (deaf or hard of hearing)	Learning difficulty (e.g. movement co-ordination difficulty (Dyspraxia, Dyslexia, etc.)
Learning impairment/disability (eg. Down's syndrome, etc)	Long term illness (eg. cancer, HIV+ etc)
Mental health condition (eg. depression, schizophrenia etc)	Physical impairment - ambulant (I do not use a wheelchair)
Physical impairment - wheelchair user	Social/communication impairment (eg. autistic spectrum disorder, Asperger's syndrome etc)
Visual impairment (blind or partially-sighted)	Other
Prefer not to answer	Don't know

Education/Student	Employment
Unemployed - Not currently seeking work	Unemployed - Seeking employment
Training	Veteran/Family Member
Prefer not to say	None

	Yes	No
Cardiovascular Disease
Respiratory Disease
Neurological Disease
Diabetes