Adult Referral

Personal Information

Full name

Date of Birth (dd/mm/yy)

Gender (Optional)

Male Female Other Prefer not to say

Current address

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

I can confirm that the person being referred lives in the Wigan Borough.

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?

Yes, I am happy for you to contact me by WhatsApp No, I do not want to be contacted 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?

YES NO

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

Tick here to agree with the storing of personal data of all persons on this form in line with Willow Project's Data Protection Policy and Privacy Notice

Please print the name of the person making this referral

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

Parents/Carers

Adult Referral Form

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