This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Rutland Living Well Active Move More by Living Well Active Who is this referral for? I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery NHS number Ethnicity SelectEnglish, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White backgroundWhite and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic backgroundIndian Pakistani Bangladeshi Chinese Any other Asian backgroundAfrican Caribbean Any other Black, African or Caribbean backgroundArab Any other ethnic groupPrefer not to say Gender SelectFemale Male Transgender female Transgender male Non-binary Intersex Not specified Not known Other Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. How can we get in touch? Phonecall Email (Emails will come from noreply-living-well-active@thejoyapp.com) Text message This field is required. How can we help you move more today? I'd like to get more active and meet new people I'd like some specialist advice about how to be active with a health condition I'd like to know what physical activity opportunities are available in my area I'd like some help to be active at home I'd like some advice about how I can stay motivated to be active I'd like to understand what and how much physical activity is beneficial I'd like more information about a particular programme/scheme Other: This field is required. If you would like to know more information about a programme/scheme - please select from the below SelectEscape Pain Exercise Referral (12 week gym based) Seated Activity Steady Steps Steady Steps Plus Walking Activities Escape Pain (Physio only referral) Do you have any physical or mental health conditions or illnesses that have lasted or are expected to last 12 months or more? Please tick all that apply Yes – mental condition or illness Yes – physical conditional or illness Yes - other No Prefer not to say This field is required. Have you ever been diagnosed with any of the following long term health conditions? Please tick all that apply: Respiratory (Lung) Conditions (e.g Asthma, Chronic Obstructive Pulmonary Disease (COPD)) Heart and Circulation Conditions (e.g Coronary heart disease, Angina, High blood pressure, High cholesterol) Metabolic and Endocrine Conditions (Diabetes Type 1, Diabetes Type 2, Obesity BMI 30+) Muscle, Bone and Joint Conditions (e.g Joint replacement, Osteoarthritis, Osteopenia, Osteoporosis, Rheumatoid arthritis, Simple mechanical back pain) Mental Health and Wellbeing (e.g Stress, anxiety or depression) In the past week, how many minutes of physical activity have you done in total, which was enough to raise your breathing rate? Less than 30 minutes (less than half an hour) 30-59 minutes (between half an hour and up to an hour) 60-89 minutes (between an hour and up to 1.5 hours) 90-119 minutes (between 1.5 hours and up to 2 hours) 120-149 minutes (between 2 hours and up to 2.5 hours) 150 minutes or more (2.5 hours or more) This field is required. Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
