REFERRAL FORM

PLEASE NOTE: This programme is only available via referral from a GP or qualified healthcare practitioners. If you meet the criteria please request a referral via your GP practice.

Please be aware that the 12 week programme costs £42. This is to be paid upfront in the venue when the customer first attends. The cost is heavily subsidised by Tees Active and is equivalent to £3.50 per week for full access to Tees Active’s full fitness provision.

Eligibility criteria:

• Aged sixteen years or over
• Resident, or registered with a GP practice, in the Borough of Stockton-on-Tees
• BMI 25+ with controlled comorbidities (23+ for people of Black African, African-Caribbean and Asian origin)

Exclusion Criteria

• An individual who does not meet the eligibility criteria as defined above
• Severe/moderate frailty as recorded on a frailty register
• Is pregnant
• Has an eating disorder
• Has a significant unmanaged co-morbidity (unmanaged meaning not on medication and/or not subject to regular clinical review or have not completed a current active management programme. Where there are any concerns that this might be the case, the individual’s GP will be consulted before commencement of the programme)
• Has had bariatric surgery in the last two years
• Has type 1 diabetes / newly diagnosed diabetes and has had no clinical input
• Has profound and multiple learning disabilities (unless actively supported by their Clinician or Carer)
• Has learning disabilities and demonstrates behaviours that challenge (unless actively supported by their Clinician or Carer)
• Mental health or learning disabilities in-patients (unless actively supported by a member of in-patient staff)
• Has an underlying medical cause for obesity and would benefit from more intensive clinical management than a tier 2 service
• Head and neck cancer patients unless explicitly supported by their Consultant Oncologist