Professional referral form – Concerned Others

Please complete the form below to make a referral to our Concerned Other service.

Important: In order for this form to be sent – cookies need to be accepted.
Red text indicates a required field, the form will not submit without this information.
If you would like to discuss your referral or have any problems, please contact Carers Leeds on 0113 380 4300 or email

Carers Leeds collects and stores personal information on the carers who come to our service for information, advice and support. When we ask for personal information we will:

  • Only ask for what we need
  • Treat the information as confidential
  • Store the information on a secure database.


    Important: Can you confirm that you have written or verbal consent in order to make a referral on someones behalf? We can not accept referral forms without the consent of the carer.

    If you have a written/physical copy giving consent, please upload it with this referral. You may upload the following files types (maximum size 1mb): jpg, jpeg, doc, docx or pdf.

    Carers details

    Cared for persons details


    Referrers details