Make a Referral

Welcome to Leeds CIL.

If you live in Leeds and you, or somebody you are working with, are interested in employing your own Personal Assistants and would like to use our PA Recruitment, Payroll and/or Managed Bank Account Services, please complete the referral form below and one of the team will contact you. If you are an existing customer who may need additional support please contact your case worker or:

Email: Independentliving@leedscil.org.uk
Tel: 0113 231 1125

Person requiring support's date of birth

Person requiring support's email address or contact number

Person requiring support

First Name of Customer (required) This field is required

Last Name of Customer (required) This field is required

Address line 1 (required) This field is required

Address line 2 (required) This field is required

Postcode (required) This field is required

Wheelchair Accessible

Yes No

Date of Birth

Contact Number

Email Address

Contact Person/Employer (if different)

First Name of Contact

Last Name of Contact

Employer

Address line 1

Address line 2

Postcode

Contact number

Email Address

Name of Professional

First Name (required) This field is required

Last Name (required) This field is required

Contact number (required) This field is required

Email Address

Duty Team Email Address

Additional Information

If you have any additional costing information please email this to: independentliving@leedscil.org.uk

Funding Stream (required) This field is required

If ADAM (PHB Only), please supply ref number:

Support Required

Equality Monitoring

We would appreciate it if you could complete the equality monitoring questions below. This will help us to know who has responded to this public engagement. The information you provide will be treated in the strictest confidence and in accordance with the General Data Protection Regulation 2018.

Gender

Age

Do you consider yourself to be disabled?

If you have said yes, what is the nature of your disability?

Other

Ethnicity

Please indicate which best describes your ethnic origin