Acacia Family Support - Ante and postnatal depression support services

Self Assessment/Referral Form

IMPORTANT
If you are a grandparent or other relative, please don't use this form. Instead use the contact us form.

Please be aware that if you are a parent under 21 there may be a delay in accessing our full service. However, please complete the referral below and we will be in touch with further information. Don't forget to make sure your midwife/health visitor and GP know how you are feeling.

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 0121 301 5990 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 for Acacia to provide you with a service you must be:
B'ham resident and registered with a B'ham GP practice:
	Yes
A Mum or dad 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 intensity service, mainly offering listening/befriending support, plus workshops. (For referrals needing higher intensity services, please consider Birmingham Healthy Minds (BHM) and/or Forward Thinking Birmingham (FTB):
	Yes
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.
Title:
First name:
Last name:
Address:
Address line 2:
Town/City:
Post code:
Tel/Mobile number:
Email address:
Date of birth:
CONSENT TO CONTACT BY
Mobile:	Yes No
Leave a voicemail:	Yes No
Text:	Yes No
Landline:	Yes No
Leave answerphone message:	Yes No
Email:	Yes No
Letter to home address:	Yes No
Gender:	Male Female Other Preferred Pronoun:
Disability/Additional Needs: e.g learning difficulties, information processing difficulties, hearing issues, access problems etc. *(Please note, if we are able to offer you an initial assessment, it will be conducted over the telephone. Please let us know how we can best support you with this assessment)*
	No Yes If yes, please specify:
First language:
Other languages:
Is an interpreter required?	No Yes If yes, please state the language below:
Emergency Contact:
Relationship:
Tel/Mobile number:
The emergency contact is the person that we would contact in the case of an emergency
Ethnic background?:	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:
Religion or belief:	I do not wish to disclose No religion Christian Buddhist Jewish Muslim Hindu Sikh Other:
How would you describe your sexual orientation?:	I do not wish to disclose Heterosexual Bisexual Homosexual
Are you pregnant?:	Yes No
How many weeks pregnant are you? (if applicable)
Number of previous births?
Expected Delivery Date? (if applicable)
Child 1:	Full name: Age: Date of birth:
Child 2:	Full name: Age: Date of birth:
Child 3:	Full name: Age: Date of birth:
Child 4:	Full name: Age: Date of birth:
MIDWIFE / HEALTH VISITOR DETAILS
Name:
Centre:
Telephone number:
GP DETAILS
GP Name:
GP Practice:
GP postcode:
GP phone:
Any other agencies/professionals involved in your care:

What agencies/medical professionals work with you: (eg. social services, Midwife, Birmingham Healthy Minds, Community Mental HealthTeam, Family Support Worker, Health visitor, befriending services, psychiatrist etc).

Using as much detail as you can please tell us how you are feeling and what sort of help you need:

Have you currently been prescribed any medication for your mental health?: If so, what have you been prescribed and since when?

Have you had previous contact with mental health services, or therapy/counselling?: (Please give the details eg dates, name of organisation and any diagnosis)
	No Yes If yes, please specify:
When did you last see your GP to discuss your mood and anxiety?:

Our usual assessment appointments are Monday to Friday between 9am and 2pm. If you have any restrictions on when you can take the call please state here (eg. working days). This will help us when scheduling your call:

It would really help us to know where you heard about Acacia and whether someone has recommended us to you. Please let us know here:

	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.

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.

Acacia Family Support
Phone: 0121 301 5990

5a Coleshill Street
Sutton Coldfield
West Midlands
B72 1SD

Phone line operates:
Monday to Friday
9:15am - 3:00pm

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