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 all members of your family 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

Other Members of Your Family

Use this section to tell us about other members of your family. 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 your family and the support you are looking for from WLAC *

21 Are you going to any other agencies?

Yes No

22 Do you 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 you are interested in receiving a service from WLAC and have consented to WLAC processing this referral. Please confirm that you consent to WLAC processing this referral with the information you have provided.

Please confirm that you consent to WLAC processing this referral with the information you have provided. Data is stored securely in accordance with GDPR regulations. If you would like to see our Privacy Policy please email team@wlac.org.uk