Pre and postnatal depression
support services
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Acacia Family Support - Ante and postnatal depression support services

Agency Referral Form


Please complete our referral form below if you would like to use our service.   There is a link to our privacy notice at the bottom of the page to let you know how we handle the information you provide.  A lot of the questions below require an answer before you can submit the form so please make sure you have completed all sections, especially the ones with red writing.  If the form won't submit it's almost definitely because you've missed a question.   If you're still having problems submitting the form please give us a ring or message us, we're here to help.
All fields highlighted in red are mandatory.

Referral criteria - Important:


In order to ensure that support is not delayed please ensure that you are sending us appropriate referrals:
Yes
No
Yes
No
Yes
No
If you have answered No to any of the above, you may wish to consider referring to higher intensity services such as Birmingham Healthy Minds on 0121 301 2525, FTB (under 25's) - 0300 300 0099, Solihull Healthy Minds on 02476 671 090 or Sandwell Maternal Esteem Team on 0303 033 9903.


Acacia offers a specialist young parent support project. Do you consider your client requires this specialist service?
Yes
No

DETAILS OF PERSON BEING REFERRED












Do you have any special requirements regarding contact from Acacia? eg. is it unsafe to leave answerphone messages?


Male
Female
Other

No
Yes

If yes, please specify:






Yes
No

I do not wish to disclose
White - British/Scottish/Welsh/Northern Irish/UK
White - Irish
Gypsy or Irish Traveller
Any other white background
Mixed ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Other Asian Background
African
Caribbean
Any other
Arab
Other:

I do not wish to disclose
No religion
Christian
Buddhist
Jewish
Muslim
Hindu
Sikh
Other:

I do not wish to disclose
Heterosexual
Bisexual
Homosexual



(if applicable)


(if applicable)










Yes
No

REFERRER DETAILS











GP DETAILS






(eg. social services, Midwife, Birmingham Healthy Minds, Community Mental Health Team, Family Support Worker, Health visitor, befriending services, psychiatrist, Home Treatment Team etc.)



SUBMIT >


We recognise that maintaining the confidentiality of certain information is necessary and are committed to practices and procedures that reflect this. We believe that information our service users give to our staff or volunteers in confidence should only be used for the purpose intended by the service user. Our staff and volunteers will not normally divulge information that could compromise a person's safety or right to privacy however there may be times when a member of staff or volunteer consider it necessary to disclose information to others within the organisation or an outside agency for the sole purpose of the safety and wellbeing and the service user and/or their family members.

Please note that information contained in this form will be stored and processed as part of our legitimate interests. Full details are contained in our privacy notice. Please ensure that the referee is aware of this.
Thank you very much for your referral.


Acacia Family Support

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0121 301 5990
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