Request for support

Please fill out the following form to access our services

Full name

Gender & preferred pronouns

Preferred name

Date of Birth

Address

Email Address

Phone

Support required, and additional information

I give consent for this referral to be forwarded to the team at Essential Space CIC for the nature and purpose of which has been explained above. I understand any personal information shared about me will be treated as confidential, some of this information may be collected and used in an anonymous form for statistical, data or research purposes. I understand that I have (i) the right to change my mind about being referred to the service and can withdraw consent and (ii) have right of access to my information (iii) that some members of our team are Counsellors in training, however this will not affect the level of care and service I will receive.

Today's Date

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