How can I refer to Live Well Leeds?

Live Well Leeds is commissioned to work with adults aged 18+ (17+ if they are transitioning from children’s mental health services), who have mild to moderate mental health support needs, throughout the Leeds Metropolitan District or registered with a Leeds GP as defined by NHS Leeds Clinical Commissioning Group (CCG).

Live Well Leeds cannot take referrals for individuals with a primary diagnosis of Dementia or Learning Disability and these individuals will be signposted to appropriate support services.

Referral Form

Reason for Referral^*

Source of Referral^*

Referrer Name

Referrer Organisation

Referrer Contact Details

Name^*

Date of Birth^*

Street Address^*

Post Code^* (If unknown, please enter 'unknown')

Telephone^*

Email Address

How do you define your gender?^*

Is your gender the same as the gender you were assigned at birth?

What is your pronoun; write your own (eg. he/him/she/her/they/them)

General Ethnicity

Specific Ethnicity

Residence Status

Disability/Sensory Impairment

Communication Needs

Do you give consent for Live Well Leeds to store your information on our electronic database?^*
I consentI do not consent

Further info required at assessment

GP Surgery

Are you subject to a CPA^*
YesNo

Do you have a social worker?^*
YesNo

Do you receive adult and health services?^*
YesNo

Relationship Status

Sexuality

Religion

Do you have a diagnosed Autistic Spectrum Condition or believe you have an Autistic Spectrum Condition but have not been formally diagnosed?^*
YesNo

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Confirm acceptance^*

^*Required Field

Referrals

How can I refer to Live Well Leeds?

Referral Form

Further info required at assessment