Service Request Form

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)
About The Person Completing This Form
Referrer Details
Referral Form
Details of Children
WCTS offers support to women on a low income only (this is with exception to the perinatal services):
* 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)
£1,625
£19,500
Couple (2 children)
£2,091
£25,092
Referral Form - Mental Health

Please specify the Casework Needs:

Note: We will not normally offer counselling whilst you are seeing another counsellor – please contact us to discuss further if this is the case.

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

We will discuss these options with you to help you work out might be most useful to you

People Who Support You
GP Details
Professionals Involved in Your Care
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