YMCA Lifestyle Managment. Programs in West

Path to Wellness Provider Referral Form
Wellness Center
5325 Langford Ave. NW
Concord, NC 28027
Office: 704-403-3050
Patient Name
Date of Birth
West Cabarrus YMCA
Phone
One
Health & Wellness
Kannapolis YMCA
Relevant Medical History
Please check specific goals for this patient:
Weight loss/management
Improve cardiovascular fitness
Improve eating habits/
nutrition
Improve flexibility
Stress reduction
Improve strength/muscle tone
Reduce chronic pain
Decrease body fat
Arthritis/osteoarthritis/
fibromyalgia
Post rehab/surgery
Post myocardial infarction Registered dietitian
consultation
(charges may apply)
Lower blood pressure
Diabetes management
Wellness Center
101 YMCA Drive
Kannapolis, NC 28081
Office: 704-403-8913
Path To Wellness Program
Harrisburg YMCA
Wellness Center
4100 Main St., Suite 200
Harrisburg, NC 28075
Office: 704-403-8913
A referral program for a healthy lifestyle change.
Other (details):__________________________________________
Exercise orders:
I approve my patient’s participation in an exercise program without restrictions
I approve my patient’s participation in an exercise program
with the following restrictions:
Carolinas Medical Center-NorthEast
920 Church St., North
Concord, NC 28025
CarolinasHealthCare.org/CMC-NorthEast
Practice Name
Referring Provider (print)
Signature
Address
City
State
Phone
Fax
Zip
Please email signed clearance form to
[email protected]
If unable to email, please fax form to 704-512-3825
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The program includes:
• Initial goal-setting consultation and weekly
check-in with your wellness nurse
• One-on-one guidance with YMCA fitness
personnel to set up a safe, effective fitness
program
• Education and tips to develop better eating
habits
• Access to all three branches of
Cannon Memorial YMCA for six weeks
Program is open to all ages and fitness
levels. Participants may include someone
who:
• Has been diagnosed with a medical condition
• Has not exercised in a long time
• Is recovering from surgery or injury
Program fee: $50
Participants are under no obligation to join the
YMCA once the program has ended. If participants
decide to join the YMCA after completion of the
six week program, the YMCA joining fee will be
waived. Financial assistance is available to those
who qualify.
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What is the Path to Wellness Program?
How do I participate?
The Path to Wellness Program is a joint effort
between Carolinas Medical Center-NorthEast and
Cannon Memorial YMCA to improve the health of
our community. The six-week program is designed
to provide guidance, encouragement and education
to help participants achieve a healthier lifestyle.
Participants may experience results such as improved
chronic health conditions, weight loss, enhanced
strength, flexibility and heart conditioning, and
overall better quality of life.
Your healthcare provider must fill out and
sign the attached referral form and email it to
[email protected]
If unable to email, please fax form to 704-512-3825
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