AABA Referral for Breastfeeding Services, Education and Support
If you are a care provider or social service provider looking to refer a client for breastfeeding services, education, or support, please fill out this form. Please be sure that your patient or client has agreed to your referral and is expecting to be contacted by us. One of our Lactation professionals will get in touch with your client within 3 business days of receiving your referral.
Please note, if you are requesting an on-call Peer Counselor, CLC, or IBCLC for a client who is currently dealing with an urgent breastfeeding matter, please call our on-call counselor line at 608-535-9525. You can also send an email to
. We do our best to accommodate these requests. Please do not send in an online referral for urgent matters!
The best way to contact your client is by:
Phone Number or Email Address
Reason for Referral:
Breastfeeding issue or concern
Infant feeding complication
Breastfeeding Support from on-call lactation professional
Peer Breastfeeding Counselor
Birth Doula Services
Community gatherings and support groups
Sister Friend with the Birthing Project
Needs breast pump
Estimated Due Date or Date baby was born
Does your client know you are making this referral?
Which of the following apply to your client?
Low Income (200% of Federal Poverty Guidelines or less)
19 years old or younger
Client or partner is on active duty in th emilitary
None of the above
Brief description of reason for referral:
Is there anything else we should know about your client?
Name of person submitting referral
Phone number of person submitting referral
Email address of person submitting referral
Name of your agency
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