Active Leeds for Health Online Referral Form

This survey is from Active Leeds at Leeds City Council.

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

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: 

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