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 Name
Last Name
NHS Number
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gender
Address
Street Address
Street Address Line 2
City
County
Post Code
Phone Number
Please enter a valid phone number.
Format: +++++ ++++++.
Email
example@example.com
Service being requested
One to one emotional stabilisation work
Post therapy support group
Continuing Mindfulness group
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
YES
NO
Please advise preferred way to contact the individual
Phone
Email
Letter
Other
Submit
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