Acacia Family Support - Support services for pre and postnatal depression and anxiety

Professional Referral Form

Please ensure that you are familiar with our referral criteria here before making the referral and if you'd like to discuss specific cases/exceptions prior to referral please ring 0121 301 5990 for assistance.

You can view our clients' Privacy Policy by clicking here, which will let you know how we handle the information you provide. It is important that the referee has read this before agreeing to a referral.

Referrals will be triaged at a weekly Wednesday meeting where a team will discuss your referral and then be in contact with any questions or extra information needed in order to understand what support is required and if we are the right service to provide this. As we are not a crisis service, we would advise you to keep in contact with your client to monitor their mental health. Please be aware that your submission of the form will not automatically mean that the client is accepted by Acacia for service and we may be in touch with more questions in due course.

Acacia provides person centred, trauma informed peer support to improve emotional wellbeing for mild to moderate pre and postnatal depression and anxiety, where the low mood or anxiety is primarily caused by pregnancy or within two years after giving birth. Peer support provides a safe and confidential, non-judgemental listening space to allow feelings and emotions to be expressed with empathy.

We will treat all people with respect, sensitivity and kindness. We expect the same values to be shown to our staff and volunteers.

Referrals for both mums and dads/partners are accepted for residents of Birmingham who are registered to a Birmingham GP.

Young Parents Service: Up to 25 years of age and Birmingham resident or registered to Birmingham GP.

Referral criteria – Important:

In order for Acacia to provide you with a service you must be:

A Birmingham resident and registered with a Birmingham GP practice:

Yes

If your client lives outside Birmingham please click here to visit the Hearts and Minds national map of available support groups.

A mum/dad/partner with a child under 2 years (or pregnant) and whose primary presenting needs are symptoms associated with ante or postnatal depression and/or anxiety, rather than circumstantial:

Yes

Suitable for Acacia's low to moderate intensity service, mainly offering listening/befriending support, plus workshops:

Yes

Parental consent gained from your client to make this referral and share any relevant information you provide with Acacia:

Yes

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. (For referrals needing higher intensity services, please consider Birmingham Healthy Minds (BHM), Specialist Perinatal Mental Health Service on 0121 301 0990, Forward Thinking Birmingham (FTB), Solihull Healthy Minds or Sandwell Maternal Esteem Team

Referrer details:

Referrer name

Job title

Organisation

ReferrerAddress

District/Town

Postcode

Office number

Mobile number

Email address

Days of work

Personal details:

Under 25s project: Acacia offers a specialist young parent support project. Do you consider your client requires this specialist service?

Yes

Preferred titlee.g. Miss/Mrs/Ms/Mr/Mx

First name

Surname

Web

Date of birth

Gender

Preferred pronoun

Telephone number

Email address

Address

District/Town

Postcode

Consent to contact We will contact your client by all the methods of contacts you have provided.

Does the client have any special requirements regarding contact from Acacia? (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)

Ethnicity

Other ethnicity

First language

Other languages

Is an interpreter required?

Yes

Religion

Disability/Additional Needs Please note, if we are able to offer an initial assessment to your client, it will be conducted over the telephone. Please let us know how we can best support this client

Sexual orientation

Other sexual orientation

It would really help us to know where you heard about Acacia services?

Other
Please specify

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

Relationship to client

Their Telephone Number

Number of births(if applicable)

Is client pregnant?

Yes

If 'Yes', How many weeks pregnant is client? (if applicable)

Expected delivery date (if applicable)

Youngest Child's age

Youngest Child's full name

Youngest Child's date of birth

Youngest Child's gender

If client has other children, please provide their details starting with the youngest to oldest:

Child 2 age

Child 2 full name

Child 2 date of birth

Child 2 gender

Child 3 age

Child 3 full name

Child 3 date of birth

Child 3 gender

Child 4 age

Child 4 full name

Child 4 date of birth

Child 4 gender

Child 5 age

Child 5 full name

Child 5 date of birth

Child 5 gender

GP Surgery name

GP Surgery postcode

GP Surgery telephone

Any other agencies/professionals involved Please indicate the frequency of this support

Reason for referral - please tell us what support you are asking us to provide? Please provide as much information as possible. Insufficient detail may delay the referral:

Supportive networks in place

Current diagnosis/history

Known triggers

What ongoing support are you providing this client, if any?

Any additional safeguarding concerns/information?

Care Plan

Risk Assessment

Child Protection Plan/Child in Need Plan

Early Help Assessment

Other

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

If you have consent to share, please email any supporting documentation to our secure email kerry.mckenna@nhs.net

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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Professional Referral Form

Referral criteria – Important:

Referrer details:

Personal details:

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