Referrals and Self-Referrals

Referral Form

Referral Form

Please complete the following form

  • If you are referring yourself you only need to complete Section 1
  • If you are a young carer (under 16) you cannot complete the form yourself and the form must be completed by an adult
  • If you are completing the form on behalf of a young carer please give contact details for their parent or guardian
  • If you are making the referral on behalf of someone else, we may need to get in touch for further information

When complete, please click the Submit button to send the form to Carers of West Lothian. If you have problems completing the form, or you get a message saying it has not been submitted, please contact CoWL by email on or telephone 01506 448000

Section 1 - The person being referred

Full Name
Full Name
Are you / they (please tick one)

Section 2 The person referring

Has consent been given by the person being referred

Data Protection: Carers of West Lothian is a Scottish Charity, registered under the Data Protection Act. We will keep your details confidential and will use them only for statistical purposes and to supply you with appropriate information, advice and services. By filling in this form and submitting it to us you consent to us using your data. You can withdraw consent at any time by contacting CoWL by telephone on 01506 448000 or email


St John’s Hospital - 01506 523000
NHS 24 - 111 / Web - NHS UK
Samaritans - 116 123 (Free from landlines and mobiles) / Web - Samaritans
Breathing Space –
Childline - 0800 1111 / Web -


West Lothian Council Social Work Services - website WLC Social Work
Out of Hours Emergency Service 01506 281028 / 281029
West Lothian Council main number 01506 280000
West Lothian Council Social Work Services 01506 282252

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Carers of West Lothian
Sycamore House
Quarrywood Court
Livingston, West Lothian
EH54 6AX

(See Google map on Home or Contact page)


Open Monday - Friday 9.00am to 5.00pm
Telephone: 01506 448000



Registered Scottish Charity No. SC019628

Company Limited by Guarantee Company Number SC226434

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