This referral form is to be completed by a Consultant or Nurse Specialist (with consultant agreement). Exercise therapy provided by Momentum Fitness Charity is for children and young people aged 5 to 18 years who are receiving or recovering from cancer treatment. It is a free service for patients to access up to 12 sessions of exercise therapy (delivered at a gym in Eastleigh, Hampshire).
High priority are children and young people who are spending considerable amounts of time sedentary and those experiencing significant negative impacts from their cancer and/or treatment which is impairing their mental, emotional and social well-being, self-confidence and/or energy levels.
It is important to note that this exercise therapy service is distinct from Physiotherapy and should not be treated as an alternative to physiotherapy where required, but rather as complementary therapy. We will consider referrals from those who are waiting for physiotherapy intervention and/or those with more significant physical impairments (temporary or long-term). If patient is currently receiving physiotherapy, please indicate name and contact details of physiotherapist on this form before submitting.
Key Referral Criteria:
1. Outpatient, between 5 to 18 years, under the care of Southampton General Hospital as their Principal Treatment Centre
2. Patient is cleared by consultant as medically fit for exercise and Exercise Therapists are fully briefed and understand patient conditions / considerations (if any)
3. Patient would benefit from engaging in physical activity for one or more of the following reasons:
Improved mood/well-being and/or Improved fitness/energy levels (reduce fatigue) and/or Reduce negative impacts of treatment-related side effects
4. Family and patient want to engage with service (and can travel to off-site gym in Eastleigh, Hampshire, where appropriate)
NOTE: We collect patient data for the purposes of delivering our exercise therapy service and data will be stored securely in accordance with the General Data Protection Regulation (GDPR). You can view our full privacy and data policies on our website: momentumcharity.org.uk Registered Charity Number 1202050 