WLAC Online Referral

WLAC Service Request Form

You should have spoken with a member of the Therapy Team already and they will have provided you with a reference number (four or five digits). Please enter this in question 2 below.

Please enter details for the Main Contact in the family in Section 1 below, and details for all other members of the family you are referring in section two. Important: please ensure you press SAVE after adding each member.

Our service is confidential and the information you provide on the following form will not be shared with a third party unless we have your explicit consent to do so.

To discuss anything on the form you can contact us on 02073521155 or 07525781373 or by emailing Team@wlac.org.uk

About You The Referrer

Referrer Borough *

Referrer Category *

First Name *

Last Name *

Job Title

Agency Name

Line 1 *

Line 2

Line 3

Town/City

Postcode *

Phone Number

Mobile Number (starting 07 and no spaces)

Preferred Contact Time

Other Members of the Family

Use this section to tell us about other members of the family you are referring. Click 'Add new family member' and complete the short form that appears. Important: Press SAVE after you have added each new family member

Add new family member

Referral Details

20Please briefly explain why you are referring this family and the support they are looking for from WLAC *

21 Is the family going to any other agencies?

Yes No

22 Does the family have any requirements to access our services? *

GP Details

23 GP Name

24GP Practice Name * (if the family do not have a GP enter n/a)

25 Line 1

26 Line 2

27 Line 3

28 City

29 Postcode

30 Telephone

Consent

It is essential that you confirm that the family are interested in receiving a service from WLAC and have consented to WLAC processing this referral with the information you have provided. Please confirm the family, adult or young person has consented to this referral being made