Make a Referral

If you are interested in employing your own Personal Assistants and would like to use our services, please complete the referral form below.

Person requiring support

Name of Customer *Please enter a value

Address line 1 *Please enter a value

Address line 2 *Please enter a value

Postcode *Please enter a value

Wheelchair Accessible?

YesNo

Date of Birth *Please select a date

Contact number

Email Address

Contact Person/Employer

Name of Contact/Employer (if different) *Please enter a value

Address line 1 *Please enter a value

Address line 2 *Please enter a value

Postcode *Please enter a value

Contact number *Please enter a value

Email Address

Name of Professional

Name

Contact number

Email Address

Duty Team Email Address

Additional Information

If you would like to include additional information with the referral or an SS2 Costing (Adults & Health), please email this to [email protected]

Funding Stream *

Adults and HealthPersonal Health Budget (PHB)PHB via the LD Joint Pooled BudgetCYPSC Direct PaymentsChildren’s PHBEducation Health Care PlanSelf-Funder

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

Support plan information

Funding approvedPA IdentifiedMBA (only)MBA (Included)

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31^stJuly, 2019 @LeedsCIL
RT @CarolReeves7: 🚨Do you employ your own care PAs to support you? 🚨We need your opinions on the https://t.co/NmDQLRw9bS recruitment… https://t.co/TiBx7JVi1u
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RT @theDTgroup: Today is #WorldEmojiDay and Apple have announced some new emojis to better represent people with disabilities - inc… https://t.co/sz0rGrYl3O
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Registered Office Address: Cartelli House, 2 Arthur Street, Stanningley, Leeds, LS28 6JY.
Registration Number: 07534989 (England and Wales) and Charity Number: 1147077.