Healthy Active Minds Referral form

Healthy Active Minds Referral Form

Health Active Minds Project is run by Edinburgh Leisure. Please fill in the details below if you are wanting to be referred to Healthy Active Minds.

Full name *

Date of Birth *

Email Address *

Please state the mental health problem *

Please state preference of activity plan(s) you would be interested in participated in. *

Yoga classes

Swimming

Gym

Exercises Classes

Walking Group

Unsure

Please state any physical impairments that might make it difficult for you to participate in certain physical activities. *

Additional Information

Are you currently taking any medication which may affect you exercising? *

Yes No

Have you been diagnosed with alcoholism / substance misuse? *

Yes No

Oops... There was an error contacting reCAPTCHA, Please try again.

Cookies on the Bangholm Medical Centre website