Which Service are you making a referral to? (If you are having difficulty completing this form online, please ring us on 0113 245 5725 and we will complete with you) We can take referrals for: * - Select -For women who are pregnant, or have been pregnant in the last 12 months, or care for an infant under the age of one.BasisLeeds City CollegeOLMPTWPNew Wortley Community Centre About The Person Completing This Form Are you making this referral for yourself? * Yes No Referrer Details Name Address Organisation Telephone Email Job Title Referral Form First Name * Last Name * Birth Date Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009 Year Gender * - Select -FemaleTransgender WomanPrefer Not to Say Address Line 1 * Address Line 2 (optional) City * Postcode * How may we contact you? * Please tick all contact methods that you give permission for (Please provide a telephone number, wherever possible, as we will need this to undertake your initial appointment) Phone Email Letter Text SMS Main phone number * Alternative phone number Email Address * May we leave a voicemail? Do not leave voicemails Do you have children? * Yes No Details of Children Name Date of Birth Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Name 2 Date of Birth 2 Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Name 3 Date of Birth 3 Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Name 4 Date of Birth 4 Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Are you pregnant? * Yes No When is your due date? Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year202320242025 Year WCTS offers support to women on a low income only (this is with exception to the perinatal services): Are you in receipt of disability benefits? Yes No Details of Disability Benefits * Are you in receipt of welfare benefits? Yes No Details of Welfare Benefits * Are you on a low income? Yes No * If you don’t know which category you fall under, please feel free to contact us on 0113 2455725. We define low income according to the HBAI poverty line for 2020, however this is a guide only and we acknowledge this is not an accurate figure for everyone. Status.Per MonthPer Year Lone parent (2 children) Status £1,625 .Per Month £19,500 Per Year Couple (2 children) Status £2,091 .Per Month £25,092 Per Year Referral Form - Mental Health Please give us a brief idea of what it is you would like some help with. * Please specify the Casework Needs: How do you hope our service might help you with these issues? * Please tell us about any practical issues that may prevent you from coming to therapy, as we may be able to support you with these Is there anything causing you particular distress or risk of harm to you or other people? (e.g. suicide attempts, self-harm, harm to others, legal proceedings, alcohol/drug use, severe eating disorder) Are you on any medication? (For mental health) Have ever you had any therapy/counselling or other support for your mental health? If so, please add dates and detail inc. if individual or group * Note: We will not normally offer counselling whilst you are seeing another counsellor – please contact us to discuss further if this is the case. Any other information that you think would be helpful for us to know? What is your availability for ongoing face-to-face counselling sessions? * Monday AM Monday PM Tuesday AM Tuesday PM Wednesday AM Wednesday PM Thursday AM Thursday PM Friday AM Friday PM Do you require an interpreter to access the service? * Yes No If Yes, which language is needed? Types of Counselling Please confirm that you would like additional support to access and engage in counselling, if so what type: We offer various types of counselling, please tick below if you are interested in the following: This request is for GROUP support only, if you would like individual support please change your selection at the top of the page Type of Counselling Creative Therapies (Using art materials) We will discuss these options with you to help you work out might be most useful to you People Who Support You GP Details Name and/or Surgery * Address * Telephone * Are there other professionals involved in your care? * Yes No Professionals Involved in Your Care Name Profession - None -Social WorkerChildren's Social WorkerPsychiatrist, Care Coordinator or other Mental Health ProfessionalHealth Visitor or MidwifeOther Telephone Number Address Name Profession - None -Social WorkerChildren's Social WorkerPsychiatrist, Care Coordinator or other Mental Health ProfessionalHealth Visitor or MidwifeOther Telephone Number Address Name Profession - None -Social WorkerChildren's Social WorkerPsychiatrist, Care Coordinator or other Mental Health ProfessionalHealth Visitor or MidwifeOther Telephone Number Address More About You How would you describe your ethnic background? * - Select -White - EnglishWhite - WelshWhite - ScottishWhite - Northern IrishWhite - BritishWhite - IrishAny other White backgroundBlack or Black British - AfricanBlack or Black British - CaribbeanAny other Black backgroundAsian or Asian British - BangladeshiAsian or Asian British - ChineseAsian or Asian British - IndianAsian or Asian British - KashmiriAsian or Asian British - PakistaniAny other Asian backgroundMixed race - White and AsianMixed race - White and Black AfricanMixed race - White and Black CaribbeanAny other Mixed backgroundArabGypsy/ TravellerAny other ethnic backgroundPrefer not to say Do you wish to access a women only service due to experience/faith/culture * Yes No Do you consider yourself disabled? * Yes No Prefer not to say Sexual Orientation * - Select -HeterosexualLesbian/Gay WomanBisexualPrefer not to say Religion * - Select -BuddhistChristianHinduJewishMuslimSikhOtherNo ReligionNo BeliefPrefer not to say Relationship Status * - Select -MarriedSingleCivil PartnershipCo-habitingOtherPrefer not to say Your Residency Status * - Select -British CitizenEU NationalsForeign StudentAsylum seekerRefugeeDestituteOthersPrefer not to say How did you hear about us? - None -I’m a previous clientFrom someone who has been a client at WCTS beforeInternet SearchPartner org: Getaway GirlsPartner org: The Market PlacePartner org: Women’s Lives LeedFrom NHS – GPFrom NHS – MidwifeFrom NHS – Mental health serviceFrom NHS – OtherFrom Social WorkerFrom other voluntary sector orgOther CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. 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