SELF REFERRAL FORM

Child’s details / Parent’s / Carer’s details
Child’s name: / Title:
Date of birth: / Name:
Gender: Male Female  / Relationship to child:
Address (including postcode): / Address (if different to child):
GP contact details: / Contact telephone number (s):
Please note: we will contact your child’s GP to inform them of your participation in Get Going
Please write what you and your child would like to achieve by taking part in the Get Going programme
We have two different services that we can offer – one is clinician led, the other is run by trained coaches in local community facilities. The next few questions help us to work out which programme will be most suitable for your needs.
Does your child have any medical conditions?
Please list any medication your child is taking:
Does your child have any significant emotional difficulties (e.g. anxiety, low mood, eating disorder)?
Does your child have any other condition for which they require additional support (e.g. ADHD, ASD, Learning Disability?)
Please list any professionals involved in your child’s care (e.g. Paediatrician, CAMHS worker, Social Worker)?
Please give details of medical/mental health difficulties experienced by other closefamily members (e.g. diabetes, disability, depression, eating disorder)?
When are you available to attend Get Going sessions (please circle)
Weekdays* /Weekends
*please note weekday courses are held afterschool hours during term time
Where did you hear about Get Going?
Child’s measurements (please complete if known)
Height (cm or feet) / Weight (kgs or stones)
Ethnic origin
Please tick appropriate box:
White
Mixed or multiple group
Asian, Asian Scottish or Asian British
Prefer not to say / African
Caribbean or Black
Other ethnic group
Do you need any language support? / Yes  No 
If yes please tell us which language:
Declaration
I declare that to the best of my knowledge there is no reason why my child should not participate in a healthy lifestyle programme. I understand that:
- We take part in any recommended programme entirely at my own risk and waive any legal recourse for damages arising from my participation
- I am responsible for monitoring my child’s responses to exercise and will inform my Get Going Coach of any new or unusual symptoms.
- I will also inform the Get Going coach of any changes in medication as soon as possible.
- The Get Going administrator will contact my GP practice for a medical summary before we can take part.
- The Get Going co-ordinator may contact other clinical staff to provide additional support for the family.
The information you provide in this form will be kept confidential and will only be used by authorised staff to help you plan and follow your activity programme. We will not share your data with anyone else except in a medical emergency. We may process data for statistical purposes but all data will remain anonymous.
Parent’s/Carer’s signature: / Date:
Preferred methods of contact (please tick): / Phone  Letter 

Please return completed form to:

Get Going Administrator, Dietetics Department,

RoyalHospital for Sick Children, 9 Sciennes Road,

Edinburgh, EH9 1LF

Tel: 0131 536 0302

Email:

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