Pre and postnatal depression
support services
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0121 301 5990
Acacia Family Support - Ante and postnatal depression support services

Young parents under 25yrs old
Referral Form


IMPORTANT
Please be aware that we currently have limited capacity to provide support to young parents due to recruitment delays.  This may cause some delay in accessing our full service for young parents.  Please complete the referral below and we will be in touch with further information.

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.

Our dads'/partners' support service is available for dads/partners in Solihull as well as Birmingham.  If you are a Solihull based dad/partner just click yes to answer the first question below.  Unfortunately we don't support mums in Solihull at the moment.
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
If the answer is yes, please use our Specialist Referral Form instead of this form
Yes
Yes
Yes
Yes
Yes
n/a
Yes
n/a
If you are not able to answer yes to all of the above, unfortunately the referral is not suitable for our service at this time. If your referral requires a higher intensity service you may wish to consider FTB 0300 300 0099, Birmingham Healthy Minds on 0121 301 2525, Solihull Healthy Minds on 02476 671 090 or Sandwell Maternal Esteem Team on 0303 033 9903.

DETAILS OF PERSON BEING REFERRED










(if known)




Does the client have any special requirements regarding contact from Acacia? eg. is it unsafe to leave answerphone messages?
(Please note that upon receipt of this referral Acacia will contact this client directly via a combination of post/email/txt/voicemail unless specified otherwise in this box).


Male
Female
Other
Preferred Pronoun:

eg. learning difficulties, information processing difficulties, hearing issues, access challenges etc.
(Please note, if we are able to offer an initial assessment, it will generally be conducted over the telephone. Please let us know how we can best support the client with this assessment)

No
Yes

If yes, please specify:





The emergency contact is the person that we would contact in the case of an emergency


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


Yes
No

(if applicable)


(if applicable)



















REFERRER DETAILS












GP DETAILS








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


Please provide as much information as possible. Insufficient detail may delay the referral:




No
Yes

If yes, please state the language below:


SUBMIT >

There are missing mandatory fields, which are indicated by red lettering stating that it is a required field.

Please check the fields and submit the form again once completed.


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

If you live in Birmingham and need help?



Need Help? If you need help or support or have any questions please call.
0121 301 5990
or click here to email us

If you live outside of Birmingham and need help?



View the website If you need help or support please visit the Hearts and Minds website.