Our Space Referral Form

To register your interest/make a referral please fill out this form. You can also register via the phone or call and arrange a time to pop in and see us to complete the form.

Name

First Last

Date of Birth

Contact details

Please list at least one way for us to contact you, this could be an email address or phone number for you or someone that supports you

Have you previously attended Our Space?

Do you consider yourself to have a disability?

If yes, please provide details of any access requirements

Do you have any relevant medical information that we should be aware of? If so, please detail.

What other support services are you currently engaged with? Where possible, please give name and contact details.

We strive to make Our Space sessions as accessible as possible. Please provide us with any information that we may need to take into consideration when planning session. For example – I struggle in large groups.

Name

This field is for validation purposes and should be left unchanged.

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Our Space Referral Form

Our Space Referral Form