VCSE/SHSC Waiting List Project Referral Form

VCSE/SHSC Waiting List Referral Form

This form enables you to apply to gain support from Space to Breathe for Wellbeing Zones, Mindfulness courses and 1:1 support in 2022.
Name of participant

First NameLast Name
Date of Birth of participant

MonthDayYear
Date of birth (MM-DD-YYY)
Name of Referrer

First NameLast Name
Which base/ward/organisation are you from?

SPA/EWSNORTH Recovery TeamSOUTH Recovery TeamEastgladeOther
Contact email
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Contact Phone Number

Area CodePhone Number
Which support at your applying for:

Meditation and Reflection for Wellbeing Course (online)1:1 Support (either face to face or online)Access to the Wellbeing Suite online resourcesWellbeing groupsBuddy/Befriender supportOther
Could you describe the wellbeing/mental health needs the person being referred has and any details we need to be aware of e.g. person needs to attend with carer, any ongoing support or care.
How can we ensure he/she is able to access the sessions and feel included. Are there any dietary needs, what access support do they require etc. We want everyone to feel safe and comfortable so do tell us anything that will help them to feel at home and welcomed.
What are the best ways to make contact with you?

EmailPhone callWhatsApp
All the information you provide here will be held safely and securely by Space to Breathe, according to the provision of our Data Protection Policy and in accordance with GDPR regulations. If you'd like to inspect the information we hold at any time, contact info@spacetobreatheuk.com.
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VCSE/SHSC Waiting List Referral Form