Service Request Form

Which Service are you making a referral to?
About The Person Completing This Form
Referrer Details
Referral Form
Contacting You

Contact Permission:

WCTS offers support to women on a low income only:
* 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 2015 to 2016
Status.Per MonthPer Year
Lone parent (2 children)
Couple (2 children)
Mental Health

Please specify the Casework Needs:

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

Types of Therapy

Please confirm that you would like additional support to access and engage in therapy, if so what type:

We offer various types of therapy, please tick all additional options you may be interested in

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 all of 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
More About You
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