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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
  • 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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