Referral form - offtheropes

Self Referral

Please read the following questions carefully and answer each one honestly. If you have any queries please contact us or speak to your Community Mental Health Team.

First Name

Last Name

Email adress

Date of birth

Phone

Emergency Contact, Name & Number

Adress

Postal code

Name of your current Mental Health Support Team and/or Care Coordinators Name and Telephone Number:

Do you have or has your doctor ever said you have a heart condition? If answered yes please give details.

Do you ever feel pain in your chest when you exercise? If answered yes please give details.

Do you suffer from high/low blood pressure? If answered yes please give details.

Do you feel faint or have dizzy spells? If answered yes please give details.

Do you have muscle, joint or back disorder which may be aggravated by exercise? If answered yes please give details.

Do you have diabetes or epilepsy? If answered yes please give details.

Do you have asthma or any breathing difficulties? If answered yes please give details.

Do you have any balance or ear problems? If answered yes please give details.

Do you have any pre/post natal difficulties? If answered yes please give details.

Are you on any medication? If answered yes please give details of medication and any side-effects you may experience.

Do you have any other issues that may affect you participating in physical activity? If answered yes please give details.

Do you have any emotional or mental health challenges that we need to be aware of? This is to help us support you best in participating in our programmed activities. If yes please give details.

Is there any other information that you would like to share with us to best support your physical, mental, emotional and general wellbeing? If yes please give details.

Participant Disclaimer & Consent

I understand that Off the Ropes sessions involve physical activity (non-contact boxing and fitness) and that, while staff will take all reasonable precautions, participation carries some risk of injury. I confirm that the information I have provided is accurate and complete to the best of my knowledge. I agree to inform Off the Ropes staff of any changes to my health or wellbeing that may affect my ability to participate safely. I understand that Off the Ropes is not a medical or clinical service, and participation is not a substitute for medical advice, diagnosis, or treatment. I consent to Off the Ropes holding my data in line with GDPR and using it to contact me about sessions and support.

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