Please note: the waiting time to see a counsellor is currently around 9/10 months, or around 3 months if someone is able to contribute £35 to each session.
Only complete this form if you live in the Wigan Borough, in the North West of England.
*Important, Please Read* – Once you have pressed the ‘submit’ button, please make sure you do not exit your browser until you have been redirected to the thank you page. If you do not get redirected or have any problems filling out the form, please get in touch.
Referral Form
(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.)
Step 1
Personal Information
Step 2
Living Arrangements
Step 3
Health and History
Step 4
History
Step 5
Contact Information
Personal Information
Full name
Date of Birth (dd/mm/yy)
Age
Gender
Current address
Please confirm that the young person being referred lives in the Wigan Borough, in the North West of England
Living Arrangements
Who does the child / young person live with and name?
Does the person that they live with know that this young person is being referred?
Contact Number and Contact Name (for when an appointment is offered)
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?
Email Address (we need this so that we can send over your counselling session details)
Permission to Contact by Letter (if needed)
Health
Doctors Surgery / Phone
Please state any health issues
Does the child/young person have any disability/access needs?
If Yes, please specify here
History
Has the child/young person ever had any involvement with CAMHS?
If yes, please give details (optional)
CAMHS - Only if you have been referred to us via CAMHS, please provide the young person's NHS number. If you don't know this, you can find it via the NHS website, https://www.nhs.uk/nhs-services/online-services/find-nhs-number/
Are you aware of any child protection issues?
Is the child/young person known to social services?
If yes, please provide the name and contact number of the young person's social worker
Is anybody in the family currently in or has been in any of the armed forces?
Is the child/young person a carer for any family member?
Does the child/young person receive free school meals?
Contact Information
Name and contact details of the person making this referral
If referral is from an agency or other professional, name of agency or organisation and address
How did you hear about Willow Project?
Please let us know, briefly, why the young person would like to see a counsellor? (N.B. Information provided may be shared with the young person)
Have these issues started or worsened as a result of the COVID-19 pandemic and lockdown?
Our weekly support groups are also available for young people, and run alongside counselling. Please indicate below if the young person would like to attend. Please note each group currently has a waiting list.
School/College (if appropriate)
Current Year Group at school (please only fill this box in if your child is interested in the Support Group)
Willow Project also provides counselling for parents/carers, and other family members of the young person accessing us. These sessions would be with a different counsellor to the one your child is allocated to, and can be on a different day to your child’s session, if you prefer. If you are interested in accessing counselling, the young person being referred won't be informed by us that you are also accessing counselling. Would you be interested in being contacted with the link to our adult counselling referral form?’
Optional Paid Service
As a charity we believe that all children and young people should have access to free counselling. However, we don’t currently have enough money to see everyone quickly and this is the reason we have such a long waiting list of 7/8 months. For parents/carers who would like to reduce this waiting time, you can do so by paying for the counselling sessions, at a subsidised cost of £35 per session. If this is the option that you would prefer, please tick below.
Please indicate whether you wish to pay for the child/young person's counselling.
Data
Do you give permission for us to share relevant information from this referral to other relevant professionals? (i.e. CAMHS)
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 Parent/Carer to give consent to this referral being made. (If you are a young person making a self-referral, please print your name below)
Once you have pressed the submit button below, you will be directed to a thank you page. Please do not exit the browser until you have been redirected to this page. If you do not get redirected to a thank you page, please get in touch. A gentle reminder that as a charity we have a lengthy waiting list, but the pandemic has had a huge impact on the service so the current waiting list is 9-10 months long, and for anyone that can contribute towards the sessions the waiting list is 2-3months long. Please make a note of our landline 01942 679300 and our mobile number 07754597646, as these are the numbers you will be contacted on when you reach the top of the waiting list and a slot becomes available.