Young mums referral form
CONFIDENTIAL
YoungMumsAid provides up to 24 sessions (6 months) of weekly counselling sessions to young mothers. The service will operate from the Brookhill and Mulgrave Children’s Centres on Thursday afternoons.
- Eligibility: Young women who are…
- Aged 16-21 years.
- Pregnant or have a baby under 2 years.
- Live in the Royal Borough of Greenwich.
- Voluntary participants and not mandated to attend counselling.
- Not attending any other counselling
As capacity is limited, we want to provide the service to those young women who are most likely to benefit. Before completing this referral form, please carefully consider…
- Does the young mother want counselling?
- Does she understand what counselling is?
- Will she be able to commit to attending weekly for a period of up to 6 months?
- Will she be able to benefit i.e. motivation, cognitive and emotional capacity to change?
We ask referrers to be prepared to support the young woman’s transition into the service.
If you wish to discuss a possible referral with a member of the YoungMumsAid team,
Please text or leave a voicemail message on 07899 661 081 and we will call you back.
General information
Todays date
This is required
Referrer’s name and organisation
This is required
Children’s Centre preference
This is required
Referrer’s location & contact details
This is required
Your email
This is required
Next
Additional information
Crèche required during counselling?
This is required
Disability/additional needs?
This is required
Presenting issues
This is required
Relevant past history
(e.g. psychiatric history, family background, domestic violence, addiction etc…)
This is required
Other agencies involved in supporting the family
This is required
Child protection plan or ‘Child-in-Need’ plan in place?
(if so, what are the implications?)
This is required
How do you see the mother benefitting from counselling?
This is required
Any possible barriers to mother attending counselling?
This is required
Any other comments or significant information?
This is required