Online Referral to Womens Counselling & Therapy Service

WCTS Referral Form.

We encourage self referrals from women as well as from other helping agencies. Enquiries can be made using either this email form or via letter or phone. If we cannot provide what you are looking for we will try to suggest another service which can.

The service is available to women regardless of their ability to pay. We do ask women who can do so to make a regular contribution, based on what they can afford.

If having read the information on our web site about the services we offer, you would like to put your name on our waiting list for an assessment, please fill in the relevant information on this form and click on the submit button. If you are not happy with the information then please press the Clear button to clear all the entries on the form.

To move between each box use the tab key on your keyboard or click in each text box using the mouse.

Please note: that the Women's Counselling and Therapy Service is for women who pay their countil tax to, or who receive council tax benefit from Leeds City Council in West Yorkshire, UK. Unfortunately we cannot take referrals from women living outside this area.

Email Address:
Full Name:
Date of Birth:
Address Line 1:
Address Line 2:
City/Town:
Postcode:
Daytime Tel No:
Mobile No:
Message:
Brief Reason for Referral:
Any Previous Therapy:
Are other people involved in your care?:
Do you have mobility problems?:
Are you a previous client?:
GP:
Is it alright for us to leave messages on the above number(s)?:	Yes No

I am interested in one-to-one therapy*
I am interested in group therapy*
I'd like to discuss what type of therapy might be helpful for me with a therapist*
We often get short notice cancellations, are you able to accept a last minute appointment?	Yes No