Third Party Referral Form

We collect the information on this form to:

· assess your loved one/patient's eligibility for our service

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

· contact you and your loved one/patient (with their consent) to deliver our service

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

Your name* This field is required.

First Name

Last Name

Your email address* This field is required.

example@example.com

Your phone number* This field is required.

Your relationship to the referee* This field is required.

Partner

Other family member

Friend

Healthcare Professional

Charity Support Worker

Other

Other (please specify)

What is your role and which Trust do you work for?

Which charity do you work for?

How did you hear about us?

Online search / Website

From a colleague

Mummy's Star Training and Education session

Leaflet, poster, printed information

Conference / networking event

Media (including TV, radio, newspaper)

Social media

Other

How did you hear about us?

Online search / Website

Friend or family member

From a Healthcare Professional

From another charity / support service

Media (TV, radio, newspaper, magazine etc.)

Social media

Other

How did you hear about us? (other)

Which social media platform?

Facebook

Instagram

Twitter / X

YouTube

Does the individual being referred give consent to being contacted by post?* This field is required.to allow us to send out care packages, information and requested resources

Yes

Unknown

Do you have their consent to refer them for Mummy's Star support?* This field is required.

YESNO

Their name* This field is required.

First Name

Last Name

Their contact email address* This field is required.

Their contact phone number* This field is required.

Their home address* This field is required.Please include the county, if possible, so we can refer them to the correct Support Worker

Their pronounsWe ask about pronouns so we can address them correctly and respectfully in our communications. This information is optional and will not affect access to our services.

Other (please specify)

Have they been in contact with Mummy's Star before?* This field is required.

Yes

Don't know

Please tell us why

Date of cancer diagnosis* This field is required.

At time of diagnosis, were they...* This field is required.

pregnant.

post-partum.

They experienced pregnancy/baby loss.

Number of weeks pregnant/postpartum at time of diagnosis* This field is required.

Did they experience...

Miscarriage

Termination for Medical Reasons

Stillbirth

Other

Details of cancer diagnosis* This field is required.(cancer type, treatment plan, medical team etc.)

Please tell us more about why they require our support. If possible, include details of their cancer diagnosis and the number of weeks pregnant/post-partum at time of diagnosis* This field is required.To be eligible for our support the mum/birthing parent must have been diagnosed with cancer during your pregnancy or within 12 months of giving birth.

Would the person you are referring like to speak to one of our Support Team to discuss options for support/signposting? * This field is required.Note: By choosing yes, you are confirming they have consented to hear from us; we cannot contact them if the answer is no.

YESNO

What kind of support are they interested in from Mummy's Star?* This field is required.Please tick all that apply

Emotional support from a Mummy’s Star Support Worker

Financial support and/or a Mummy’s Star grant (please check our website for eligibility)

Peer support online forums

Other

Unknown

What other kind of support?

Do you have any other questions or information that you'd like to share with us, that will help us support you or the referee?

Before accessing any of our support the referee must provide copies of ID documents including: a passport or other photo ID, proof of cancer diagnosis, proof of pregnancy. Please indicate you understand this is a requirement and that any problems should be raised with a Support Worker as soon as possible.* This field is required.Note: referrals made by CNSs do not require copies of ID.

I understand that the referee will be required to provide copies of ID and related documents to access Mummy's Star support.

Before accessing our support, the referee will be asked to provide copies of the following ID documents:

a) Letter confirming their diagnosis*
b) Photo ID (e.g. passport, driving license)
c) Proof of address (e.g. utility bill)

(*If their diagnosis letter does not reference pregnancy/the birth of their 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 but you don't need to provide them now to progress with the referral. Please complete this form whether you attach documents or not.

Would you like to upload any ID documents at this time?

YESNO

Please upload copies of the following: a) diagnosis letter b) Photo ID c) Proof of address d) ante-natal letter / child's birth certificate if required

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

You have chosen to provide these documents at a later date.

I confirm that the referee will provide copies of the requested ID documents as soon as possible, via email. I understand that they must provide these documents before they can access support from Mummy's Star.

Our Promise

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

We only contact you and the referee 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.

We will contact the person being referred initially by email. Please let us know if they are also happy to be contacted by any of the following methods. By selecting any option, you are confirming that the individual consents to being contacted by this method regarding their referral.* This field is required.Tick all that apply

Telephone call

Text message

Post (this allows us to send care packages, information and requested resources; UK residents only)

Accessibility requirements (optional)We want to make sure everyone can access our services comfortably. Please let us know if your loved one/patient has any specific access requirements so we can provide appropriate support.

Would you like to sign up to a Mummy’s Star newsletter? (tick all that apply)* This field is required.You can unsubscribe at any time by clicking the link in the footer of our emails. We promise to keep your data secure and will never sell your data. For information about how we protect your data and our privacy practices, please see our Privacy Policy

Yes, I am a Healthcare Professional and I would like to know the latest in research, case studies and training opportunities from the Mummy’s Star Health Care Professionals Newsletter.

Yes, I would like to keep up to date on the latest events, impact and opportunities to get involved from the Mummy’s Star Supporter Newsletter.

No, thank you.

Finally, do you consent to Mummy's Star communicating with you and storing the data you have provided? If you do not, you will not be able to submit this form and the data you have entered will be deleted.* This field is required.

I consent to Mummy's Star communicating with me and storing the data provided in this form for the reasons described. I understand I can remove my consent at any time.

I do not consent to Mummy's Star communicating with me or storing the data in his form and I would like it to be deleted.

AgeWhich age group do they fall into?

Under 18 years

18-24 years

25-34 years

35-44 years

45+ years

Prefer not to say

Living situation and relationshipWhich of the following best describes their current living situation? This information is optional and can help us signpost any support that may be available.

They live alone and do not have a partner

They live alone and have a partner who lives elsewhere

They live with their husband, wife, or partner

They live with their parents or other relatives

They live with friends or housemates (non-relatives)

They live in supported or sheltered accommodation

Prefer not to say

Children at homeDo they currently have any children living in their household? This information is optional and can help us signpost any support that may be available.

Yes, 1 child

Yes, 2 children

Yes, 3 children

Yes, 4 or more children

Prefer not to say

Their ethnicityWhat ethnic group do they identify with?

Asian or Asian British

Black, Black British, Caribbean or African

Mixed or multiple ethnic groups

White

Other ethnic group

Unknown / Prefer not to say

Asian or Asian British

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background

Black, Black British, Caribbean or African

Caribbean

African

Any other Black, Black British, or Caribbean background

Mixed or multiple ethnic groups

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed or multiple ethnic background

White

English, Welsh, Scottish, Northern Irish or British

Irish

Gypsy or Irish Traveller

Roma

Any other White background

Other ethnic group

Arab

Any other ethnic group

Their religion or beliefs

No religion

Christian

Muslim

Hindu

Sikh

Jewish

Buddhist

Other

Unknown / Prefer not to say

Other (please specify)

Consent

Yes, I consent to Mummy’s Star processing and storing this information for research, equality monitoring, and to help tailor the support I or the referee receive. I understand that this information will be treated confidentially and will not affect my or the referee's ability to access services.

No, I do not consent to Mummy’s Star processing and storing this information. I understand that this will not affect my or the referee's ability to access services.