SPS Space to Breathe Referral Form

Space to Breathe Support for Specialist Psychology Service (SPS) Patients

Referral for the project between Space to Breathe and SPS for 1:1 Emotional Stabilisation work (before or after therapy), Post-Therapy support group and the Continuing Mindfulness group.
Name and role of person referring from SPS
Email of person referring from SPS
example@example.com
Details for Person Being Referred
Name of person being referred

First NameLast Name
NHS Number
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Phone Number
Please enter a valid phone number.Format: +++++ ++++++.
Email
example@example.com
Service being requested
Reason for referral (please give brief summary of issues which have led to the referral, how long have these factors been going on for and what is the impact on their quality of life?)
Are there any factors we need to be aware of to ensure we can allow this person to fully take part in the service? (assessibility/practical)
Please advice any risk factors identified (if any)
Any other information to be aware of e.g. diagnosis, physical health issues etc
Does the patient consent to being involved in this service & to being contacted
Please advise preferred way to contact the individual

Other
All data collected is stored in line with UK GDPR legislation and Space to Breathe's Data Protection Policy which you can find here - https://spacetobreatheuk.com/looking-after-your-data.

Space to Breathe holds confidential data securely and to the highest standards. We always consult individuals on first appointment to confirm data arrangements and gain their consent.
Should be Empty:

Space to Breathe Support for Specialist Psychology Service (SPS) Patients

Details for Person Being Referred