Burngreave & Pitsmoor: Emotional Wellbeing (free/funded) referral

Burngreave & Pitsmoor: Emotional Wellbeing 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 Burngreave and Pitsmoor Emotional Wellbeing Project, funded through "This is 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.'
Details of person to be supported
Name of participant

First NameLast Name
Date of birth of participant

MonthDayYear
Date of birth (MM-DD-YYYY)
NHS Number (if known)
Address of person being supported

Street Address

Street Address Line 2

CityCounty

Postcode
Contact Phone Number of person being supported

Area CodePhone Number
Contact email for person being supported
example@example.com
Self-referringReferral from organisation
Details of referrer (if relevant)
Name of Referrer (if applicable)

First NameLast Name
Contact details for referrer (if applicable)
SHSCPrimary CareOther NHSVCS organisationLocal CouncilOther
Details of support requested

Select as many as needed
General 1:1 Support (either face to face or online)Access to online/app wellbeing resourcesWellbeing courseLearning MindfulnessRestorative Yoga (for women only)Crafting 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.
EmailPhone callWhatsApp
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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Burngreave & Pitsmoor: Emotional Wellbeing Referral

Details of person to be supported

Details of referrer (if relevant)

Details of support requested