Wellbeing support (free/funded) referral

Wellbeing support (free/funded) referral

This form enables you to apply to gain support from Space to Breathe for 1:1 work, groups and activities provided free of charge under the Men's Mental Wellbeing Programme, Space to Breathe's ongoing emotional stabilisation work or if you've agreed to refer someone to us. Please complete all sections of the form. Data will be held securely under our GDPR policy. If you are self-referring, please ignore questions about referring organising and tick 'self-referring.'
Name of participant

First NameLast Name
Date of birth of participant

MonthDayYear
Date of birth (MM-DD-YYYY)
Self-Referring or being referred by an organisation?

Self-referringReferral from organisation
Name of Referrer (if applicable)

First NameLast Name
Contact details for referrer (if applicable)
Which base/ward/organisation are you from? (for referring organisations only)

SHSCPrimary CareOther NHSVCS organisationLocal CouncilOther
Contact email for person being supported
example@example.com
Address of person being supported

Street Address

Street Address Line 2

CityCounty

Postcode
Contact Phone Number of person being supported

Area CodePhone Number
Which support is being applied for:

General 1:1 Support (either face to face or online)Access to online/app wellbeing resourcesMen's Mental Wellbeing ProjectMen's Wellbeing Wellbeing & Emotional Stabilisation supportMen's Wellbeing GroupsBurngreave and Pitsmoor Group supportCrafting Calm groupsOther
Could you describe their/your wellbeing/mental health needs (for the person we will be supporting) 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 you/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 to ensure everyone feels at home and welcomed.
What are the best ways to make contact with you?

EmailPhone callWhatsApp
Is it ok to make contact on receipt of this form?

YesNot yet
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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