• Baby Bank Service Referral Form

  • This form is to request items from PCC(S)'s Baby Bank for any child from birth up to the age of 2 years old.

    This form can be used by the following groups:

    -Professionals who are requesting items for a client who has not used the baby bank before
    -Professionals who are requesting items for an existing baby bank client
    -Existing baby bank clients who have received support from us in the last 2 years

    If you have not received support from us before, or your last request was more than 2 years ago, you need to re-referred by your midwife or health visitor.

    Please fill out this form as thoroughly as you can. Some sections are mandatory and some are optional, we will mark clearly at the start of each section whether the information is essential to us processing your request.

    Incorrect or incomplete information may prevent your request from being completed.

    The items that we provide are second-hand but have been thoroughly checked cleanliness as well as health and safety compliance.

    If you have any questions about our service please visit our website www.counsellingandcare.co.uk to find out more about the service.

  • Are you a health or social care professional or are you a existing Baby Bank client (a family that has previously used this service)?*

  • Health or Social Care Professional Details

  • Please provide answers to all the following questions about your personal information.

     

  • Please indicate that you are happy for us to store these details electronically in order to contact you, the referrer, about this referral, and about future updates on the Baby Bank service
  • OLD Is this your first time making a referral with us?*
  • Is this your first time making a referral with us?

  • Client Details

    This section will ask about details of the primary caregiver of the family you are referring.
  • OLD Proving family details means that we can contact families about this current referral, families can make subsequent self referrals, and will be able to access our Christmas Service. Please indicate that the family are happy for us to receive their personal details and store these details electronically
  • Providing the family’s details allows us to contact them about this referral and enables them to make future self-referrals. Please confirm that the family has given consent for us to receive and securely store their personal information electronically.
  • Client's preferred method of contact

  • Monitoring Form

    This section of the form provides PCC(S) with knowledge about who is accessing our service. This really helps us when applying for grants which help keep our service running. Please provide as much monitoring information as possible.
  • How many adults are in the family?
  • How many children are in the family (including how many are expected)?
  • Reasons for referral: in addition to the previous question, please let us know the reasons that apply to you or the family you are referring (select all that apply)*

  • Information about Baby

  • Child 1 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 2 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 3 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 4 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 5 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child 6 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this pack for a baby that is not yet born or one that is already here?*

  • Newborn Request

  • When is the baby's due date?*
     - -
    2 digit day, 2 digit month, 4 digit year
  • What type of pack is needed?*
  • Please mark which items are required*
  • Do you need to request items for additional children?*

  • Clothing & Equipment Request

  • Would you consider reusable nappies?*
  • CLOTHES - Girls. Please tick all sizes needed.
  • CLOTHES - Boys
  • SHOES - Girls
  • SHOES - Boys
  • Equipment - please mark every item that is needed

  • Counselling Service

    PCCS also has Counselling Service for anyone looking for support due to pregnancy-related issues or early parenthood. Issues we regularly support people with include pregnancy anxieties, post-birth support, stillbirth and miscarriage. We offer up-to 10 sessions of counselling delivered online or in-person. For more information you can visit http://counsellingandcare.co.uk/home/counselling/
  • Would this service be of use to the person you are referring to the Baby Bank? If yes, please inform the service user that you have made this referral for counselling.
  • If yes, has the referee/your client given consent for the counselling team to contact them in regards to this service?

  • If you are happy to submit the provided information, please press 'Submit'. If not, press 'back' to change your entries.

     

    Apr 2026: The current waiting time for any referrals made is approx. 4 weeks, but if it is urgent we will try to get it out sooner

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