Our use of cookies

We use necessary cookies to make our site work. Necessary cookies enable core functionality such as security, network management, website analytics and accessibility. You may disable these by changing your browser settings, but this may affect how the website functions. The cookies collect information in a way that does not directly identify anyone. For more information on how these cookies work, please see our privacy policy.

To agree to our use of cookies, click the 'Accept' button. No, give me more info

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

There are no results that match your search criteria