Baby Bank Referral Form

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.
Please confirm that you have read everything above before continuing with your request*

I have read all of the above
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 ProfessionalExisting Baby Bank Client

Health or Social Care Professional Details
Please provide answers to all the following questions about your personal information.
Full Name*

First NameLast Name
What Organisation do you work for? (If you are NHS Staff, could you inform us of your office/practise base)*
Is this your first time making a referral with us?*

YesNo
Email*
example@example.com
Phone Number

Client Details

This section will ask about details of the primary caregiver of the family you are referring.
Client Name*
Client's preferred method of contact*

PhoneEmailText
Client's email address
Client's phone number*
Please provide a delivery address. **PLEASE NOTE: If items are being delivered to addresses which are NOT the families home (ie, health centered or staff offices), please ensure the deliveries can be accepted at these locations**

Street Address

Street Address Line 2

CityState/Province

Postcode

Information about Baby
How many children are being referred to our service? Please provide age and gender of each child.*
Is this pack for a baby that is not yet born or one that is already here?*

Baby not yet bornBaby already born

Counselling Service

PCCS also offers free to access, professional counselling to anyone suffering due to pregnancy or early parenthood. Issues we regularly support people with include pregnancy anxieties, post-birth support, stillbirth and miscarriage. We are able to provide 10 online sessions of counselling delivered via Zoom, a secure online platform.
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.

YesNo
If yes, has the referee/your client given consent for the counselling team to contact them in regards to this service?

YesNo
Please provide further information regarding the circumstances of the client you are referring for counselling

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

10.01.23: The current waiting time for any referrals made is approx. 4 weeks
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Baby Bank Service Referral Form