Milk&You Registration Form

Are you a...

ParentProfessional

We cannot accept referrals from friends or family members due to data protection laws.
We must have consent from the parent in order for a referral to be made.

If you are a professional please complete the form using the parents details. There is a section at the end of the form to add your own information.

Which area are you registering for? *

*** We accept registrations and referrals from outside of these specific areas (you do not have to live in these areas to access support BUT you (the parent) MUST live in Northamptonshire).

Full Name of Parent*

First NameLast Name

Address of Parent*

Street Address

Street Address Line 2

Village/Town/City

Post Code of Parent*

Street Address

Street Address Line 2

Post Code

Date of Birth (Mother/Parent)*

DayMonthYear

Baby's (Babies) Date of Birth

Date

Telephone Number (please enter your full number without country code e.g. 07867 758 3747)*

E-mail of Parent*

example@example.com

What is your first language (parent)? This is so we can arrange a translator if needed.*

If you are pregnant, what is your babies due date?

This information lets us know when to contact you to offer antenatal education and feeding support after the birth.

We collect contact details to ensure we can provide you with information about our services. Personal data and contact details will be entered into our database called CharityLog which allows us to collect information for the purpose of reporting data. It also allows us to document activities that happen between Milk&You and yourself (such as when you attended a group or which volunteer supported you). We also would like to contact you with any changes to our support services/events. You will also be provided with information about what we do and how you can access the range of help we offer.

Please let us know how you feel about this below.*

I do not wish to have my name, address, contact number and email stored on your database for the above purposes.I am happy for you to use my data anonymously for the purpose of reporting information, but do not wish to be contacted with information about services.I would like to receive information about your services and I am happy for you to store my details (name, address, contact number and email).

Photographic consent

I am happy for you to take photographs of me in a public spaceI am happy for you to take photographs of me for the use on social mediaI am not happy for you to take photographs of meI am not happy for photographs (even when taken with my consent) to be published on social mediaI am happy for you to take photographs of my child for the use on social mediaI am not happy for you to take photographs of my child

How did you hear about us/who referred you to our service?*

If you selected 'other' for the above question, who told you about us?

Please specify here who told you about us/how you heard about us if the option was not listed above.

Current Feeding Type: How are you curently feeding your baby/toddler/child?*

Feeding Goal: How do you want to be able to your baby/toddler/child? If you are pregnant you can still answer this question, but don't worry if you don't know yet.

How old is your baby/toddler/child? Please complete a separate form for another child should you be tandem feeding/need support for both infants. You do NOT need to complete a separate form if you have twins.*

What service do you need?*

If you are currently receiving support via the Early Help team or a social worker please provide the name and contact number of the professional.

We are currently supporting mothers to breastfeed after birth, and we have another support service for those mothers who have stopped smoking cigarettes in pregnancy, to offer extra stress relief support via MUM Support volunteers in partnership with stop smoking services. If you are a mum who has smoked in the last 2 years during pregnancy, you are also able to use this service. Please contact Izzie on 07376348568.

Would you like help to stop smoking cigarettes? Only answer if you ARE currently smoking cigarettes.

Yes I would like help to stop smokingNo I do not want help to stop smokingI have given up and would like help to stay smoke free

Please tell us more about the support/information you require. You can explain a specific feeding problem here, or ask a specific question about feeding. You can also tell us what items you need from our donation bank/what event you would like to attend.

This information helps us to help you more quickly and offer the services most relevant to you.

What NHS Trust is providing your maternity/health visiting care?*

Northampton General Hospital NHS TrustKettering General Hospital NHS Foundation TrustNorthamptonshire Healthcare NHS Foundation TrustOther

Register with Milk&You (Northamptonshire)

Professionals Details ONLY