BOOBS Self Referral Form 2025
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Email *
Mother's First Name *
Mother's Last Name (Surname) *
Mother's Ethnicity *
Mother's Age Group *
Required
Baby's Age Group *
Baby's Age
(Please write "pregnant" if this is an antenatal referral request)
 *
Post Code *
Appointment Preference *
PLEASE READ FIRST.

Please select all options you are comfortable with. 

Depending on location, we cannot always accommodate face to face appointments but we do try!

We rarely carry out home visits. If you need a face to face appointment and can't get out for a medical reason (such as baby being under 7 days old or you having had a c-section) or cultural reasons, then please make detailed notes in the 'other' section explaining why you feel this is the option for you. If you just write 'home visit' then this will be declined and you will be contacted asking to choose an alternative appointment preference.

If you choose a "stay and play" appointment, we will contact you to book you in for a face to face appointment. The current stay and play location, weekday and times are:
Emmanuel Church, 174 Langworthy Road, Salford, M6 5LX - Wednesdays, 10:30am-12pm, term time

If you selected Home Visit above: do you have dogs or other pets? Please include pet (e.g. dog/cat) and number of pets:
If you selected Home Visit above: what type of home do you have? (Single-story house/Flat/Shared house/if other, please specify)
Contact Number *
Please describe the issue(s) you would like help with *
To help us triage your referral appropriately, please indicate if you are experiencing any of the below (please tick all that apply) *
Is English your first language? *
If English is not your first language, please state your first language below, and if you require a translator for appointments.
Form Submission (a) *
Form Submission (b)
If you are completing this form about someone else, and have not informed them, please indicate why you have not informed them. Please do not share confidential information about someone without their permission.
I confirm that I consent to B.O.O.B.S sharing this information with B.O.O.B.S trained Breastfeeding Peer Supporters and appropriate colleagues.

(Tick the box below to consent)
 *
Required
I confirm that I consent to B.O.O.B.S sharing this information with relevant B.O.O.B.S partners such as the Bury Infant Feeding Team or Salford Homestart, for the purpose of referring to these services.

(Tick the box below to consent)
 *
Required
How did you find out about B.O.O.B.S? *
Required
If you replied "other" to where you heard about B.O.O.B.S, please could you say how you found out about B.O.O.B.S below?
BOOBS is part of the Greater Manchester campaign to increase awareness and uptake of The Healthy Start Scheme. BOOBS may be able to offer assistance to families to access Healthy Start.

Do you currently claim Healthy Start vouchers?
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