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

Self Assessment/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.  If you haven't heard anything back in a week's time please contact us.
All fields highlighted in red are mandatory.

Referral criteria - Important:


In order for Acacia to provide you with a service you must be:
Yes
No
Yes
No
Yes
No
Personal information: (Please answer each question as fully as possible. We will share any relevant information with your GP).

Acacia has a duty of care to ensure you and others are safe. Please note if you tell us anything that suggests you or someone else is at risk, this information will be shared with an appropriate agency.

If you have had no contact from Acacia within 7 working days of returning your form please contact the office on 0121 301 5990 to confirm receipt.

Please note that information contained in this form will be stored and processed by Acacia as part of our legitimate interests. Full details are contained in our privacy notice. Please ensure that you are aware of this before submitting this form to us.











CONSENT TO CONTACT BY

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

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)











MIDWIFE / HEALTH VISITOR DETAILS





GP DETAILS







Please can you tell us who you live with? Include any children and their ages









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





For example, your strengths, resources, family, friends, interests etc.


If so, what have you been prescribed and since when?


If so, please tell us more ...


(Please give the details eg dates, name of organisation and any diagnosis)
No
Yes

If yes, please specify:



Please include activities and times, e.g. get up at 7am.


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.

Acacia Family Support

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

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