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.

Referrer

Create a new referrer

Referrer’s email(Required)

Referrer’s name(Required)

Referrer’s Organisation(Required)

Referrer's contact address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Referrer's Office telephone

Referrer's Mobile telephone

Family’s home address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Family telephone no.

Preferred means of contact

Call

Text

Babies Name

Babies DOB/EDD

Babies Ethnicity

Do you have any other children?

No

Yes

Details about your other children

GP name(Required)

GP Practice Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GP Contact Telephone(Required)

Health Visitor Name(Required)

HV Clinic Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Health Visitor Telephone(Required)

Children’s Centre preference

Mulgrave

Brookhill

Crèche required during counselling?

No

Yes

Disability/additional needs?

Presenting issues

Relevant past history (e.g. psychiatric history, family background, domestic violence, addiction etc…)

Other agencies involved in supporting the family

Child protection plan or ‘Child-in-Need’ plan in place? (if so, what are the implications?)

No

Yes

How do you see the mother benefitting from counselling?

Any possible barriers to mother attending counselling?

Any other comments or significant information?

Have you referred this mum to any other services?

No

Yes

If yes, please list which services you have referred to

Where did you hear about MumsAid?

Where did you hear about our service?: Other

Young mums referral form

Create a new referrer