Building Bonds Project Client Referral Form
This form is for recognised health care professionals (midwives, health visitors, nurses, GP's, paediatricians etc.), social workers or charity case workers to refer families where one member has ante- or postnatal depression or anxiety, (or is at high risk of developing this after birth), PTSD, bonding issues, or a child with serious illness or disability. Baby carriers can also be a very useful tool for children in the foster care system; helping to rebuild secure attachments and to act as a tool to aid transition between homes.

We will assist with the safe use of a sling, which can help with building bonds, as well as allowing parents to be hands free, making life more manageable. If the family is in financial hardship (such as in receipt of healthy start vouchers) we will provide free support. Please note that we are a not-for-profit enterprise and are mainly staffed by volunteers.

Please confirm you are filling this form in for a client or patient and that you have checked our criteria (https://bit.ly/2LrQiTQ) *
Required
Client/patient's first name *
Your answer
Client/patient's second name *
Your answer
Age of child (or estimated due date) *
Your answer
Client/patient's email address
Your answer
Client/patient's telephone number
Your answer
Client/patient's address including post code *
Your answer
Preferred method of contact (please select at least one. Without this, we will be unable to arrange support) *
Required
Referring Organisation *
Your answer
Please provide details of any other agencies currently involved with the family
Your answer
Can you describe briefly why you are referring and provide any other information that you think will be useful when we are assessing which of our services will be most appropriate? (e.g. relationship/attachment difficulties with the baby; mental health history, type of illness/disability, including prognosis if relevant) *
Your answer
Are there any safeguarding issues (adult and/or child) of which we need to be aware? *
If you have answered Yes to the above question, please give details
Your answer
Do you believe the family are in financial hardship, for example in receipt of healthy start vouchers, with no recourse to public funds or other financial difficulty? (If there is no financial challenge, please refer them to the sling library service (sheffieldslingsurgery@gmail.com) *
Does the client/patient have a good command of spoken English? *
If you have answered "No" to the above question, will they be able to bring someone who is competent at interpreting for them?
If you have answered "No" to the above question, what language or languages are they able to converse in? (We will endeavour to arrange support, but this may not be possible).
Your answer
Referee's first name *
Your answer
Referee's surname *
Your answer
Date *
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Job Role *
Your answer
Date verbal consent was obtained from referee (Please note that without consent, we will not be able to help the client) *
MM
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DD
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YYYY
Your contact phone number
Your answer
Your contact email address *
Your answer
How did you hear about the Building Bonds Project? *
Your answer
Please confirm you have read our privacy policy and are happy to proceed - https://bit.ly/2LoP3oH *
Required
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