Recovery Space Outreach Support
We provide four one-to-one non-clinical support sessions in your community for people in mental health crisis, Monday to Friday: 9am-5pm. Eligibility; person over 18 years, living in Croydon/registered with a Croydon GP. What is a mental health crisis: Feeling in need of urgent mental health help, overwhelming distress, thoughts of self-harm or harming others, suicidal thoughts. If you are worried about your immediate safety or have thoughts about hurting yourself or other people: Call 999 for emergency services.
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Address
Address 1
Address 2
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Demographic
Gender
Please choose a value
(Do not use )Transgender (Do not use)
All Other Gender Identities
Female
Male
Non-binary
Not stated
Prefer not to say
Trans Man
Trans Woman
Ethnicity
Please Select
Asian Other
Black Other
Arab
Asian Bangladeshi
Asian Chinese
Asian Indian
Asian Pakistani
Black British African
Black British Carribean
Mixed Other
Mixed White and Asian
Mixed White and Black African
Mixed White and Black Caribbean
Other ethnic group
Prefer not to say
Unknown
White British
White Gypsy or Irish Traveller
White Irish
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White Roma
Contact
Telephone
Email
Service Related Information
Communication Restrictions?
Please choose a value
Yes
No
Unknown
Additional Notes including access requirements
Other Information
Description of mental health i.e. relapse indicators, triggers
Please give contact details for professional support received
Do you give consent to contact these professionals?
Yes
No
Is there any additional support you require?
The last 3 months, have you had any support for mental health?
GP
Supported housing
Probation service
Community treatment team
Care Coordinator
Drug or alcohol services
Social Services
Other Mind Service
MHPIC
Other
None of the above
Where were you referred from?
Please Select
Fairfield House Recovery Space
New Addington
Old Coulsdon
Purley
South Croydon
Thornton Heath
Are you experiencing one or more of these symptoms of mental health crisis?
Feeling in need of urgent help
Overwhelming distress
Suicidal thoughts
Thoughts of self-harm or harming others
Consent
Consent to Receive Further Communication?
Please choose a value
Yes
No
Unknown
In Case of Emergency contact
In Case of Emergency (ICE) Name
ICE relationship to the Client
ICE phone number
Submit