Strength and Balance/ Active Workplaces Online Referral Form

Introduction
Please Note this is not the referral form for L.E.A.P. Leeds Encouraging Activity in People (L.E.A.P) referrals will NOT be processed if this form is used. Please speak to your GP or Health Care Professional if you require a referral into L.E.A.P 


Strength & Balance Eligibility Criteria:

• Age 60+
• At risk of falls or have recently fallen
• Any health conditions must be controlled (we need you to provide evidence from a health professional)
• Health professional has confirmed you are safe to participate. 

Active Workplaces Eligibility Criteria:

• Health and Wellbeing coaching is available to a select number of businesses that are in an annual contract for Corporate Health and Wellbeing.
• This service is available to any employee within organisations that are in an annual contract.
• For employees that are not based in Leeds this service may be delivered via digital or telephone media.
• Health and Wellbeing coaching is available for anyone who is experiencing health challenges within the workplace and would like extra support.
• If you are unsure you should check with your Health and Wellbeing Lead within your own business.
• Health and Wellbeing coaching can benefit all employees and can provide positive support, motivation, advice and mentoring.

All self-referrals will be contacted via a phone call. You will be assessed for suitability before we can offer a place on our programme.

To access the health programmes you will need to get in touch, or fill in the enquiry form below.
This can be a self-referral or a referral from a health professional.

In some circumstances we may require more information from your health professional and ask for a more detailed referral form to be completed. You can also complete this form online at https://active.leeds.gov.uk/active-leeds-for-health.

Before you complete the from please watch this SHORT VIDEO.

Privacy notice (data protection)
The information you provide on this form will only be used in order to administer your referral for the Active Leeds Health Programmes. The council is the data controller of the information you provide and we are processing this data, contractually, in order to provide this service to you (and, in the case of 'special category' health data, in order to provide the care programme you require).

We will share your information with Leeds City Council, Leeds Community Healthcare, Leeds Clinical Commissioning group, West Yorkshire and Harrogate Integrated Care System for research and evaluation purposes. the personal information you provide will be held for a period of 12 months following your last know contact with the service, after which it will be securely destroyed.

The council's corporate privacy notice, which includes details of the authority's Data Protection Officer and your Information Rights is available at: https://www.leeds.gov.uk/privacy-statement/privacynotice 

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