15 Gertrude Street, London, SW10 0JN

Tel: 020 7352 1155 Fax: 020 7351 2739 www.wlac.org.uk Email:

REQUEST FOR A SERVICE

West London Action for Children offers FREE and CONFIDENTIAL counselling and groups

To families on low income who live in Kensington & Chelsea and Hammersmith & Fulham

If you would like to meet us to discuss your or your family’s needs, please fill in this form and send to us

Please indicate which of our services you might be interested in:
Counselling for parents/carers, families, children Breathing Space a mindfulness-based
ParentTalk a group for parents of 3-12 yr olds stress reduction group
ParenTeen a group for parents of teenagers ParentPlay play therapy skills for parents
Dads Matter a group for fathers
The person for us to contact in the family:
Name: / Date of Birth: Age:
Address: / Tel:
Mobile:
Postcode: / Email address:
Borough:
/ Can we leave a message on your phones?
Home: Yes No Mobile: Yes No
Please describe your ethnicity for monitoring purposes: / School/College:
(if applicable)
Our services are for people on low income Please tick which benefits you are eligible for :
Tax Credits Universal Credit Income Support Jobseekers allowance
Name of other family members & significant others / Date of Birth / Relationship to Main Contact / Name of School or College (if applicable) / Age / Ethnicity
(for monitoring purposes only)

FOR WLAC OFFICE USE ONLY

Consultation by: Allocated to: Date case closed:

Registered charity number 1135648 Registered Company number: 07181950

President: The Duchess of Richmond and Gordon

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What help would you like from West London Action for Children?
Are you going to any other agencies? If yes, please provide details
Do you need any assistance to access our services? Please provide details
We can provide interpreters and childcare and have ramp access
Does your child or children have a child protection plan? Yes No
Or a child in need plan? Yes No
Name of GP:
Address:
Tel No:
FOR REFERRERS If you are referring this person/family on their behalf:
It is ESSENTIAL that the person or family is interested in receiving a service from WLAC
Please confirm the family, adult or young person is interested in our services Yes No
All information on this form will be shared with the client
Details of the Referrer:
Name: / Name of Agency:
Address: / Job Title:
Tel:
Postcode: / Mobile:
Borough: / Email:
Best time to contact you:
Any additional information you would like to give:

PLEASE RETURN THIS FORM TO WLAC AT THE ADDRESS ON THE FIRST PAGE

West London Action for Children complies with the Data Protection Act and confidential information is kept secure. Access to it is restricted to the professional team at WLAC.

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