Baby Bank Referral Form

Baby Bank Service Referral Form
This form can be used by the following groups:

-Professionals who are requesting items for a new (to us) client
-Professionals who are requesting items for a current client
-Current 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 current Baby Bank client or are you a health or social care professional making a request for a family? *

Current Client Health or Social Care Professional

Health or Social Care Professional Details
Please provide answers to all the following questions.

After completing this section you will be taken to the 'Client Details' section. The only required answer in that section for you is the 'name' part as we use this as a reference and we will contact you when the items are ready.

Alternatively if you would like to refer the client so they can make their own requests in the future you will need to provide all the details that are asked for.
Full Name *

First Name Last Name
What Organisation do you work for? *
Is this your first time making a referral with us? *

Yes No
Email *
example@example.com
Phone Number

Information about Baby
How many children are being referred to our service? *
Is this pack for a baby that is not yet born or one that is already here? *

Baby not yet born Baby already born

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

Update as of 27.06.2022: The current waiting time for any applications made is 5 weeks.
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Baby Bank Service Referral Form