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.

URL

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

Thank you for your interest in Our Space. This form helps us understand how best to support you (or the person you are referring).

Please complete as much as you can, you don’t need to answer every question if it doesn’t apply. You can also make a referral by phone or arrange a time to visit us and complete the form together.

Are you completing this form for yourself, or on behalf of someone else?

Details of the person being referred

Name

First Last

Date of Birth

Preferred contact details

Please provide at least one way for us to get in touch. This can be the person’s own details or those of a trusted supporter.

Have you/they previously attended Our Space?

Referrer details - please complete this section if you are making a referral for someone else.

Your full name

Organisation (if applicable)

Your role

Phone

Relationship to the person being referred

Additional information to help us support you

Do you consider yourself to have a disability?

If yes, please tell us about any access requirements or adjustments we should be aware of

Is there any relevant medical or health information we should know about?

(For example: allergies, medications, mental health considerations.)

Are you currently engaged with any other support services? If possible, please include the service name and contact details.

We aim to make Our Space sessions as welcoming and accessible as possible. Please tell us anything that may help us plan sessions effectively.

(For example: difficulty with large groups, sensory sensitivities, communication preferences.)

How did you hear about Our Space?

Anything else you'd like us to know?

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Our Space Referral Form