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Advice, support and care for adults
Help with your life
Debt Respite Scheme
Mental Health Breathing Space online form
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The Debt Respite Scheme (Breathing Space)
Mental Health Breathing Space online form
Mental Health Breathing Space online form
Your voice matters
We're committed to improving our services. Share your thoughts on the Adult Social Care section of the Staffordshire County Council website by participating in
our survey
.
Individuals information
Name
First name
Last name
Address
Address Line 1
Address Line 2
City
County
Postcode
Country
NHS number
Date of birth
Phone
Email
Initial assessment
Does the referred individual believe that disclosing their address to their creditors may lead to violence against them or a family member?
Yes
No
If yes, please give reason
By making this referral you are confirming that in your judgement the individual (named above) is receiving mental health crisis treatment
I confirm
Please detail your reasoning for applying for the Mental Health Crisis Breathing Spaces protection
Does the referred person have the capacity to consent to a referral to the Breathing Space Scheme?
Yes
No
If
yes
, this referral will be processed on the basis that you have gained their consent
If no, the person being referred will need to engage in an assessment to determine whether they can make informed decisions about their finances. If this has taken place, please provide details including who was it that engaged the person in the assessment and their contact details
If you can provide any information about the debts the person owes or their income please give details below:
Next Page
Ongoing support
Nominated point of contact (NPC)
NPC role
NPC phone number
NPC email
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Referrer details
Name
Role
Phone
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