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Mummy's Star Self Referral Form

Mummy's Star Self Referral Form

Please fill out as much of this form as possible. There are four sections and it should take approx. 10 minutes to complete. If you have any questions or need assistance completing the form in a different way, please contact us directly info@mummysstar.org
39Questions
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    We collect the information on this form to:

    · assess your eligibility for our service

    · understand and tailor our support to meet your needs when engaging with our service

    · contact you to deliver our service

    All information you provide will be stored securely, treated confidentially, and used only for these purposes.

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    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    We ask about pronouns so we can address you correctly and respectfully in ourcommunications. This information is optional and will not affect your access toour services.
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    -
    Pick a Date
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    To be eligible for our support, cancer must have been diagnosed during pregnancy or within 12 months of giving birth.
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    Which of the following best describes your current living situation?
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    Do you currently have any children living in your household?
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    Please tick all that apply
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    Before accessing our support, you will be asked to provide copies of the following ID documents:

    a) Letter confirming your diagnosis* (don't worry if you haven't received this yet, we may be able to confirm with your nurse)
    b) Photo ID (e.g. passport, driving license)
    c) Proof of address (e.g. utility bill)

    (*If your diagnosis letter does not reference your pregnancy/the birth of your baby, we also need a copy of an antenatal letter or the child's birth certificate.)

    All documents will be deleted after being seen by one of our Information & Support Workers.

    These documents must be seen by Mummy's Star before any support is accessed and you will be asked to submit your documents in the next question. Please continue this referral form even if you don't have your ID documents yet, you will be able to submit them at a later date.

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    Please note: you do not have to upload all the documents to continue
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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    Our promise

    Your personal details are very important to us here at Mummy’s Star. We will never share your information with other organisations, without your explicit consent, unless we are required to by law.

    If you receive our support, we only contact you with support information, news, updates or opportunities we hope you will be interested in.

    We won’t bombard you with emails.

    You can opt out of communications with us at any time by emailing info@mummysstar.org.

    You can read more about data retention, use and deletion in our Privacy Policy here.

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    (tick all that apply)
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    We want to make sure everyone can access our services comfortably. Please let us know if you have any specific access requirements so we can provide appropriate support.
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    to allow us to send out care packages, information and requested resources
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    Which group do you fall into?
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    Which ethnic group do you identify with?
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    What is your religion or belief?
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