Adult Referral

ONLY COMPLETE THIS REFERRAL FORM IF YOU LIVE IN THE WIGAN BOROUGH, IN THE NORTH WEST OF ENGLAND

Parents/Carers

Family issues and supporting young people can also be difficult, and if you feel that you or any other adult family member would also like support from us, then please fill out the adult referral form below.

(Please note: this form is more compatible with laptops/computers or by ticking ‘switch to desktop version’ when using a mobile phone, as the formatting is different on a mobile phone.)

Adult Referral Form

Step 1

Personal Information

Step 2

Health and History

Step 3

Contact Information

  • Step 1
  • Step 2
  • Step 3

Personal Information

Full name

Date of Birth (dd/mm/yy)

Gender (Optional)

Current address

Please confirm that the person being referred lives in the Wigan Borough, in the North West of England

Email

Mobile Phone

We try and use WhatsApp where we can, as it is a secure and free messaging service. Are you happy for us to contact you via WhatsApp?

Are you the parent/carer to a young person that has accessed Willow Project? Name of young person:

Health

Doctors Surgery / Phone

Please state any health issues

Do have any disability/access needs?

If Yes, please specify here

Referral Information

If this referral form is being completed by another agency or professional, please give contact details and name of the organisation

Please give a brief description of what has triggered this referral

Have these issues started or worsened as a result of the COVID-19 pandemic and lockdown?

Data

By ticking the box below and printing your name, you are agreeing to Willow Project storing data of all persons named on this form in line with our Data Protection Policy and Privacy Notice, details of which can be obtained from Willow Project on 01942 679300

Please print the name of the person making this referral

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