Request Help

Are you a mother experiencing distress or symptoms of depression or anxiety? We would like to provide you with some support. Please complete the form below – Mothers Helpers keeps all of the information that is filled out below in a confidential file that only our counselling team can access. We do not share any of your details unless we are concerned about your safety or the safety of someone else and we would not do this without talking to you first.

Please also use this form if you would like to refer someone who you may think is in need, or are concerned for.

Referral Form

Tick the risk factors that apply:*
- Antenatal Depression/Anxiety
- Postnatal Depression/Anxiety
- Unplanned pregnancy
- Single mum
- Financial difficulties
- Relationship difficulties
- Sick child
- Less than 6hrs continuous sleep
- Breastfeeding issues
- Previous depressive episode
- Traumatic birth
- Poor family support
- Domestic Violence
- None of the above
Name*
First Last
Do you have a Community Services Card?*
- Yes
- No
Date of birth*
DD slash MM slash YYYY
Ethnicity*
Email*
Enter Email Confirm Email
Home Phone
Mobile Phone*
Address*
Street Address Address Line 2 City ZIP / Postal Code
Name of GP*
Name of Midwife (if applicable)
Names and Date of Birth of children in your care*
Are you interested in attending a PND Recovery Course?*
Are you interested in attending a Preparing for Parenthood Course*
Where did you hear about Mothers Helpers
Comments/Anything Else?
If you are making a referral for someone else, please enter your name, organisation and contact details below:
Consent*
- Has this mother given her consent to be contacted by us
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