Personal Assistant Register

Disability North  Personal Assistant register 

People in need of support and looking for PAs can download and complete the online referral form here and email it to

To see our FAQs for employers, personal assistants, or Local Authorities please click on the relevant link.

For more information contact our team on
or by telephone  0191 2840480.

 Individual employers can submit a referral for support, as well as Social workers, Care managers and other support organisations.

    Please complete all fields below

    7. Gender (we are asking this as some people may prefer a PA of the same gender)?

    8. Are you looking to support Adults and/or Children?

    9. Can you provide support with live-in care?

    10. Can you provide overnight care?

    11. Please indicate which hours you would be available for work and tick all that apply:








    12. Could you work extra hours at short notice?

    13. What areas of the region are you available to work in?
    [checkbox regions-county-durham use_label_element "County Durham]

    14. Do you have a Valid UK Driving Licence?

    15. Do you have access to a car to use for work purposes?

    16. Would you be willing to drive a wheelchair accessible vehicle which may be larger than a standard car?

    17. Are you comfortable working around pets?

    19. Would you be prepared to work in a house where smoking is not permitted?

    20. Do you have a current DBS certificate (less than 3 years old)?

    22. Do you have permission to work in the UK?

    24. Can you provide personal care including washing, dressing and help with using the toilet? Please tick all that apply:

    25. Can you provide support with any of the following? Please tick all that apply:

    26. Do you have any training/experience in the following (you may be asked for proof)? Please tick all that apply:

    27. Have you worked as a Personal Assistant before?

    34. Please give the details of two people who have agreed to act as referees for you. One must be a current or most recent employer if you have one and neither should be a close member of your family.

    Current/recent employer:

    Contact following interview but prior to job offer?

    Second reference:

    Disability North will hold your data securely. However, to accept your support we may need to share your details with trusted partners (e.g. Local Authority Social care/Local CCGs and the Individual employers). Your details will not be shared anywhere else. Are you happy for us to do this? *

    I confirm that, to the best of my knowledge the information I have provided on this form is accurate and that I have not altered or omitted any facts which may have a bearing on the PA support I am able to provide *