Medical Professional Referral Form

West Northamptonshire Pickleball CIC invites you to partner with us on our PowerPlay Pickleball initiative, a structured, evidence-informed programme designed to address inactivity and health inequalities in our community.

We provide a safe, low-impact pathway to improved physical and mental well-being for your patients, particularly for adults with a Body Mass Index (BMI) of 30 or over. The programme is led by Director Kate Vincent, a qualified Level 3 GP Referral professional with expertise in exercise and behaviour change.

How to Refer a Patient

We have made the referral process as straightforward as possible. You can refer a patient by completing our online form or by using our printable PDF document.

Online Referral Form: This is the quickest and most secure way to submit a referral. Please fill in the form below.

Printable Referral Form: If you prefer a physical document, you can download, complete, and return our referral form via secure email.

GP PowerPlay Pickleball Pack.pdf

Please fill in the form...

Referring Practice Details

Practice name

Referring GP/Clinician/Link Worker Name:

Phone:

E-mail:

Date of Referral:

Patient's Personal Details

First name

Last name

Phone

Address

Birthday

Day

Month

Year

Gender

Male

Female

Other

Prefer not to say

Reason for Referral and Relevant Information

Height (cm)

Weight (kg)

Current BMI (if known)

Brief Medical Summary

Please provide any relevant medical history or conditions (e.g., knee pain, high blood pressure, type 2 diabetes) that we should be aware of to ensure safety and adapt the programme.

What are the main health/well-being goals for this patient? (e.g., increase physical activity, weight management, improve mood, social connection, chronic condition management, etc.):

Consent and Submission

I confirm that the patient has given their explicit consent for this referral to West Northamptonshire Pickleball CIC.

I understand WNP will contact the patient directly within 3 working days to arrange their participation.

Medical Professional Referral Form

How to Refer a Patient

Please fill in the form...

Referring Practice Details

Patient's Personal Details

Reason for Referral and Relevant Information

Consent and Submission