WCTS Referral form – Flying Lessons
Date:
Personal Information
Name:
Date of birth (DD-MM-YYYY):
Address:
Additional needs (E.g. mobility):
Postcode:
Income:
Telephone:
Email:
Mobile:
Children Under 18:
Name
Date of birth
Name
1.
4.
2.
5.
3.
6.
Date of birth
Are you pregnant? YES / NO
I would like to access a women-only service due to reasons of past or current experience, faith or
culture: YES / NO
Contacting you:
Is it ok to leave a message on your mobile/landline? YES / NO
Can we contact you via text? YES / NO
Can we send you letters via email? YES / NO
Are you interested in short notice appointments if we have a cancellation? YES / NO
How would you prefer being contacted by us? Email / Text / Letter
Availability for therapy slot: Morning / Afternoon / Evening
WCTS offers therapy to women on a low income only:
Are you in receipt of disability benefits (YES/NO)? If YES please give details:
Are you in receipt of welfare benefits (YES / NO)? If YES please state which:
Are you on a low income*? (See next page) YES / NO
*Low-income: If per week your household income (after tax), is at or under the figure below, you are eligible to use our
service.
Are you single and living alone? £280
Are you living with partner and three children? £727
Are you living with a partner? £420
Are you a lone parent with one child? £420
Are you living with partner and one child? £559
Are you a lone parent with two children? £503
Are you living with partner and two children? £645
Are you a lone parent with three children? £587
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 DWP’s HBAI report (June 2012).
Referrers Details
Name:
Organisation:
Address:
Email:
Telephone:
Professionals Involved in your care
General Practitioner (GP)
Name, Address and Telephone number:
Psychiatrist or other Mental Health Professional
Name, Address and Telephone number:
Adult Social Care Service (E.g. Home Care, Day Services etc.)
Name, Address and Telephone number:
Any other professionals involved in your or your children’s care (E.g. Support worker, Social
worker)
Name, Address and Telephone number:
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Mental health
Please give us a brief idea of what it is you would like some help with.
How do you hope therapy might help you with these issues?
Risk factors (E.g. suicide attempts, self harm, harm to others or alcohol/drug use)
Current medication (For psychological issues)
Previous therapy (please give dates).
Note: we will not normally offer therapy whilst you are seeing another therapist – please contact us
to discuss further if this is the case.
Any other information that you think would be helpful for us to know?
Type of therapy:
We offer group and individual therapy. There are usually shorter waiting times for our groups. If you
are interested in thinking about a group, we can arrange an initial discussion with one of our group
therapists. Please circle/tick one of the following:
Individual
Group
I would like an initial discussion
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About you:
How would you describe your ethnic background? Circle/tick any that apply
White
Mixed
Asian/ Asian
British
Black/ Black British
Other ethnic group
English
White and Black
Caribbean
White and Black
African
White and Asian
Indian
Caribbean
Arab
Pakistani
African
Gypsy/Traveller
Bangladeshi
Any other Black background
Any other ethnic
Background
Any other mixed
background
Kashmiri
Welsh
Scottish
Northern Irish
Prefer not to say
British
Chinese
Irish
Any other Asian
background
Any other
white back
ground
Is your gender identity different to the sex you were assumed to be at birth?
Yes
No
Prefer not to say
Your sexual orientation: Circle/tick any that apply
Attracted to Men and Women
Attracted to Men
Attracted to Women
Prefer not to say
Do you consider yourself disabled? YES / NO / Prefer not to say
If YES, how does this affect you
Your religion: Please circle/tick any that are relevant
Buddist
Christian
Hindu
Jewish
Muslim
Sikh
Other
No Religion
No Belief
Prefer not to say
Your residency status: Circle/tick any that apply
British Citizens
EU Nationals
Asylum seekers
Refugee
Others
Do not know residency status
Foreign Students
Destitute
Prefer not to say
Married
Co-habiting
Civil Partnership
Single
Other
Prefer not to say
Your relationship status
Signed: ___________________________________________________________________________
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Please return this completed form to us by post or email.
WCTS, Oxford Chambers, Oxford Place, Leeds LS1 3AX // [email protected]
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