REFERRALS

Email office@carers-westlothian.com | Tel 01506 448000

Referrals and Self-Referrals

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 office@carers-westlothian.com or telephone 01506 448000

Section 1 - The person being referred

Full Name

Date of Birth

Are you / they (please tick one)

A carer

A person with a disability

A Young Carer (age 8-18)

If they are a young carer, give the name of parent or guardian

Relationship to the young carer

Please use the space below to tell us about your situation, or that of the person being referred

Home telephone

Mobile number

Email address

Section 2 The person referring

Name

Service

Has consent been given by the person being referred

Yes

Please tell us why you are making this referral

Telephone

Email address

Signed

Date

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 office@carers-westlothian.com

EXTERNAL QUICK LINKS

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

HELP OUT OF HOURS

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