Request for attending a group/event/workshop

Please fill out the following form to access our services using the person who is attending details.

Full name

I wish to attend

Gender & preferred pronouns

Date of Birth required

Address or school/collage attending

Email contact

Phone

Please provide details of what you are wanting to attend - and if you have any access requirments or known allergies

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 or mental health professionals in training, however this will not affect the level of care and service I will receive.

Today's Date

Thanks for submitting! We will be in touch as soon as possible