Health Programmes online enquiry form

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Get Involved

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 Age UK who are responsible for supporting your transport needs, Leeds Beckett University, North of England Commissioning Support Unity (NECs) and Leeds Intelligence Hub, our programme partners, 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 

Leeds City Council are collecting and processing your personal information in response to the NHS test and trace. This will assist the council to effectively fulfil our functions to safeguard public safety, in risk of harm or emergency situations and to support Public Health England to minimise the transmission of COVID -19.
This information is being collected as part of the NHS test and trace scheme and will only be used where necessary to help stop the spread of COVID-19. In line with Government guidance, customer contact details will only be shared with the NHS if you have visited us within 21 days from the date the information is collected.  After this point, your details will not be shared with the NHS and will be retained by us according to the privacy notice above. Details of your rights under UK Data Protection legislation, including details of the Council’s Data Protection Officer, your rights as a Data Subject, and your right to complain to the Information Commissioner’s Office are available at the following link: https://www.leeds.gov.uk/privacy-statement/privacy-notice

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By ticking the box below, you are agreeing to us sending you updates, on physical activity and/or sports related events you may be interested in. Leeds City Council would also like to use the contact details that you have provided on this form to offer you information on other Leeds City Council leisure related activities and events.

Would you like to take advantage of this offer? *

 

If you would like to hear from us, then please provide your contact details below.

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What is your date of birth? *

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What best describes your sex?

 

What is your ethnic group?

  • White
  • Mixed / Multiple ethnic groups
  • Asian / Asian British
  • Black / African / Caribbean / Black British
  • Other ethnic group