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Please complete this referral form to refer a client to the WAFER service (Wellbeing and Financial Empowerment Resource) delivered by West Central London Mind. The WAFER service provides practical and emotional support for individuals experiencing mental health challenges, financial stress, or wellbeing-related difficulties.

This form is designed for Citizen's Advice Staff to complete with or on behalf of clients. Please include as much relevant information as possible to help us make timely contact and ensure the client is supported appropriately.

Once submitted, a member of the West Central London Mind team will review the referral and get in touch directly with the client. If any additional details are required, we may contact the referrer before proceeding.

Client Contact Details and Address

First Name

Last Name

Mobile Phone Number

Telephone Number (Landline)

Address Line 1

Address Line 2

Town / City

Post Code

Borough

Client Demographics - We are committed to supporting anyone affected by mental health difficulties to live the life they choose. Answering these questions helps us to understand who is accessing our services and who we need to work harder to reach. The information you provide will be treated with strictest confidence.

Date of Birth

Gender

Is the clients gender different to the sex they were assigned at birth?

Ethnicity

Sexuality

Religion

Does the client consider themselves to have a disability?

Referrer Contact Details

Name of Referrer

Referrer Email

Referrer Telephone Number

WAFER Referral Information

Only to be used within the WAFER service

Has the client consented to a referral being made to the WAFER service?

Has client been informed that someone from the WCL Mind team will be in touch with them?

What is the client's primary reason for accessing Citizen's Advice?

Why are you referring this client for mental health support? Please provide as much information as possible about this client's mental health difficulties (e.g. struggling with anxiety/depression/low mood/stress/relationship issues/PTSD etc.)

Is this the clients first time seeking mental health support?

Does the client have a formal mental health diagnosis? If so, please specify.

Is there any imminent risk present that referrer is aware of (ie. that the client may harm themselves or others)?

Does the client have any disability/ specific access needs?

Are there any other comments/ concerns about the client that you would like to share?

Session location preference

WAFER Service Referral Form

Client Contact Details and Address

Referrer Contact Details

WAFER Referral Information