When filling in this form please ensure that the information you provide is accurate. 

The more detail we have about why you are making the referral the quicker we will be able to follow up on your request for support. 

We would recommend that you complete this form whilst you are with the woman you are referring.

Please add you own contact information first and then add your referral's details in the following sections. 

After submitting a referral form to Birth Companions, you will receive an email from our Administration Officer, or your specific contact at Birth Companions, to confirm receipt of the referral. Thereafter, the woman referred can expect to be contacted directly by one of our Services Coordinators. 

Please explain this in advance to your referral to help her to feel prepared and willing to speak to the Service Coordinator when they contact her. 

Our Service Coordinators are all female, will always introduce themselves by name and will say they are from Birth Companions. 

Please note that we are only able to offer support to women in the community in London


Referral Form

LANGUAGE ISSUES - IS THE WOMAN BEING REFERRED ABLE TO COMMUNICATE IN ENGLISH

(optional)

HAVE YOU TALKED TO YOUR POTENTIAL REFERRAL ABOUT THE SUPPORT AND SERVICES BIRTH COMPANIONS CAN OFFER HER?

IS THE WOMEN BEING REFERRED/ INTERESTED IN ATTENDING OUR ANTENATAL CLASSES IF SPACE IS AVAILABLE? (optional)

IF NOT, IS SHE INTERESTED IN BIRTH SUPPORT FROM US (nb this is dependent on area and availability of our volunteers)

IF THE WOMAN BEING REFERRED HAS ALREADY HAD HER BABY OR IS VERY CLOSE TO GIVING BIRTH WOULD SHE BE INTERESTED IN ATTENDING OUR POSTNATAL GROUP IF SPACE IS AVAILABLE?

DO YOU HAVE AGREEMENT FOR THIS REFERRAL? (optional)

DO YOU HAVE CONSENT TO SHARE INFORMATION WITH US? (optional)

Communication preferences

Birth Companions is registered in England and Wales under charity number 1120934 at Dalton House, 60 Windsor Avenue, London SW19 2RR. We use cookies to improve your experience using this website.
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