CANW → Referral form for Emotional Therapeutic Service

Referral form for Emotional Therapeutic Service

The Emotional Therapeutic Service only accepts referrals for those aged 15+ who are on the Building Better Opportunities Project. If your referral is for a person under 15 years of age, please use the following link:

http://www.lancashirechildrenstrust.org.uk/resources/?siteid=6274&pageid=44490 and choose option;

Request for support (e-form)

Referral form

Please complete the referral form here. So the referral can be actioned quickly please ensure you complete as much of the information as possible. We aim to triage the referral within 7 days of the referral being received, we will keep you updated if we are experience any delays or need to come back to you for further information.

Fields marked with an * are required.

Key contacts

Tel: 01254 244703
Email: ETS@canw.org.uk

Which project is the participant on?*

Views ID number:*

Date of request:*

Referrer organisation:*

Email of referrer:*

Contact number of referrer:*

Participant start date:*

Location of participant:*

Session preference:* Face to face sessionsSessions via phoneSessions via Zoom

If a participant would like to access face to face sessions, do you know of a suitable venue? If so, please give details. If not, we may be unable to facilitate this, as we have been struggling to find spaces which are private, accessible and available.

Does the participant have any diagnosed mental or physical health conditions?*

Are you aware of any potential risks? ie: alcohol/substance misuse, aggressive behaviour, criminal convictions etc

Is the participant currently on a waiting list or currently accessing any other wellbeing/counselling service?

Reasons for request of support. What is the nature of their difficulties?

Privacy options:

I confirm I have read the privacy policy

Opt-in for email communications

We offer 8-10 sessions and work with low level support needs. Below are some of the things that we can offer support with.

Building confidence and aspirations
Managing negative relationships
Talking about feelings and emotions
Taking control of chaotic lifestyles
Improving personal health and wellbeing
Developing coping strategies

If you are unsure if the participant is suitable for this service, please contact us and we will provide further information about our service.

Referral Form

Referral form for Emotional Therapeutic Service

Referral form

Key contacts