Professional referral form

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Note for Dementia Referrals

We are currently taking much longer than we would like to respond to dementia carer support referrals. This is likely to be the case for the next 3 months.

Please only refer if you have identified a specific need for carer support with the family member. Please state this need clearly on the referral.

If the referral is regarding welfare benefit support, we are currently signposting these request to other organisations. A downloadable information pack for carers can be found here.

If you would only like the carer to be registered with Carers Leeds please state this in the referral form. We will then send out an information pack to the carer with details of how to contact us. If you would like to speak to someone about your referral please contact our Advice Line on 0113 380 4300. Thank you for your understanding at this time – We will continue to update you on our situation in due course.

    Consent

    Important: Can you confirm that you have Written or Verbal consent in order to make a referral on someone's 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

    Does the carer pay council tax to Leeds City Council? If no please state which authority.
     

    Communication and Support Needs.

    Important information about the Carer

    Cared for persons details

    (The cared for person is the individual with the disability or illness)
    Does the person being cared for pay council tax to Leeds City Council? If no please state which authority.
     

     

    Referrers details