Online referral form

This information will be treated as private and confidential. Derbyshire County Council ensure this information is held securely and processed in accordance with the Data Protection Act 2018. Information will only be shared between organisations when required for the delivery and monitoring of the lifestyle interventions provided.


Clients known to have any of the following health issues are unable to participate in an exercise programme until the health issue has been controlled or resolved:

  • Unstable angina
  • Uncontrolled/poorly controlled diabetes
  • Uncontrolled or poorly controlled hypertension (resting blood pressure of greater than 180 systolic or 100 diastolic) 
  • Ventricular aortic aneurysm
  • A significant drop in blood pressure on exertion
  • Uncontrolled tachycardia (greater than 100 beats per minute at rest)
  • Unstable or acute heart failure
  • Uncontrolled arrhythmia
  • Febrile illness
  • Section 1: Client details
  • Section 2: Eligibility criteria and health conditions
  • Health conditions
  • Other health services
  • Section 3: Consent and referrer details
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