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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 16-19 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
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About the mother

Mother’s Name

This is required

Mother’s DOB

This is required

Mother’s Age

This is required

Mother’s Ethnicity

This is required

Mother’s Home Language

This is required
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Family details

Family’s home address

This is required

Family telephone no.

This is required

Preferred means of contact

This is required

Babies Name

This is required

Babies DOB/EDD

This is required

Babies Ethnicity

This is required

Other children names and DOBs

This is required
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Health Visitor & GP Details

Health Visitor assigned

This is required

Health Visitor Tel no

This is required

GP name

This is required

GP Address

This is required

GP Telephone no.

This is required
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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
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