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Mental Health Breathing Space online form


  • Individuals information
  • Name
  • Address
  • Initial assessment
  • Does the referred individual believe that disclosing their address to their creditors may lead to violence against them or a family member?
  • By making this referral you are confirming that in your judgement the individual (named above) is receiving mental health crisis treatment
  • Does the referred person have the capacity to consent to a referral to the Breathing Space Scheme?
  • If yes, this referral will be processed on the basis that you have gained their consent

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