Hi, Ibu! Hang in there, we are here to support you.
Please fill up this form below to your best ability so that we can accommodate your need as soon as the next peer counsellor is available.
Email address *
First, we need to know a little bit about you
What is your name? *
Your answer
What is your age? *
Your answer
What is your contact number? *
Please enter your active phone number that we can Whatsapp or call (e.g. 018-274523 or 01113495338)
Your answer
What is your employment status? *
Which state are you in? *
Which city are you in? (or the closest city) *
Your answer
Tell us briefly about the breastfeeding issue you are having
We would like to be prepared when we visit you and baby.
How old is your baby? *
Your answer
What type of delivery did you have? *
Is your baby born full term or premature? *
If born premature, how many weeks early is he/she? (Leave blank if not applicable)
Your answer
Are you facing any of these issues? *
Required
How are you feeding your baby? *
Any other comments and/or questions?
Your answer
Additional Information
Once you submit this form, our team will match you up with a peer counselor in your area. Please allow up to 48 hours for the initial contact. In the event of an absence of peer counselors in your area, a home visit might not be possible but we will do our best to provide support via telephone while pulling more resources to find the next available trained personnel.

MBfPC is a network of trained breastfeeding peer counselors to support, protect and promote breastfeeding in the community.

Our trained Breastfeeding Peer Counselors are support persons with knowledge, skills and ethics in supporting breastfeeding.

We need more support persons to make our network stronger, find out more: https://malaysianbfpc.org/about/

Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy