Refer a child or young person to Winston's Wish

Referrals from adults for young people over the age of 13 will not be accepted.

For young people aged 13 or over, we ask you to complete a referral form with or encourage the young person to complete their own referral.

For professionals: We encourage parents and children to complete their own referral form. Please be aware that missing or incomplete information may cause your referral to be declined.

If you disclose information where we deem you or your child/young person to have suffered or be at risk of harm, abuse or neglect, we are legally obligated to share details with the relevant authorities.

Contact details of the person making the referral

Are you the parent or carer for the child being referred?

YesNo

Contact details of Professional making the referral

Relationship to the child/young person

Profession Sector

Have you contacted any of our On Demand Services (Help/Support Line, Live Chat or ASK Email) prior to completing this form?

YesNo

Please be aware that if you have not contacted any of our On Demand Services prior to completing this form, your referral may be delayed or declined.

First name

Last name

Contact phone number type

Contact phone number

Contact email address type

Contact email address

How did you hear about Winston's Wish?

Please specify

Have you contacted any of our on-demand services? (this could be our helpline, email or live chat)

YesNo

Contact details of the parent or carer

First name

Last name

Phone number type

Phone number

Email address type

Email address

Mailing Street

Town/city

County

Postcode

Relationship to the child or young person

Child or young person's details

First name

Last name

Pronouns

Pronouns - Other (please specify)

Date of birth

Please use DD/MM/YYYY format

Age

Mailing Street

Town/city

County

Postcode

Ethnicity

Please specify

What gender does the child or young person identify as?

Please tell us

Their main language

Please specify

Does the child or young person have any religious or spiritual beliefs?

YesNo

Please tell us more:

Where does the child or young person go to school?

What doctor's surgery/GP is the child or young person registered with?

Does the child or young person have any special education need/s or disability?

YesNo

Please provide details

Is the child or young person in a specialist setting?

YesNo

Does the child or young person have an EHCP or ELSA?

YesNo

Who does the child or young person live with?

Can you advise when would be best to call you, should we need to get in touch?

Hearing from Winston's Wish

We would like to share ways for you to stay connected with Winston’s Wish beyond the service you will be receiving both now and in the future. This will include news of events and ways to support our work including fundraising and volunteering. The services you receive from us will in no way be impacted by your choice to support our work. You can opt out of these communications, should you wish, at any time.

Yes, I'm happy to hear from Winston's Wish by Email

Yes, I'm happy to hear from Winston's Wish by Post

Yes, I'm happy to hear from Winston's Wish by Phone

Yes, I'm happy to hear from Winston's Wish by Text Message

By submitting this referral form you are agreeing to share your information with us. If you would like to read our privacy policy please click here

I understand and agree

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