Active NAtion

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We Have Your Referral

  • Thank you for completing your referral form. We’re just checking the information you’ve given us and, we will be in touch shortly to book an initial consultation.
  • Did you also know we run FREE community sessions across Southampton?
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1. SUITABILITY QUESTIONS

Do you / the person you are referring currently exercise less than 5x30 minutes a week?*

Unfortunately you are not eligible to join this programme.

Please check out our other community programmes.

Do you / the person you are referring currently have a health condition?*

Unfortunately you are not eligible to join this programme.

Please check out our other community programmes.

Are you an organisation making this referral on behalf of an individual?

2. PERSONAL DETAILS

Participant details:

Gender

Address:

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3. HEALTH CONDITIONS

Medication:

Health Conditions:

GP Details:

I understand that my details will be stored on a secure database system in an appropriate confidential manner. I agree to be contacted in relation to this referral with the details I have provided.