Refer a Mum

If you would like to refer a mother to receive our free support service, please complete the form below with your client’s permission. Our services are available nationwide. As a result of this referral, a clinician specialising in Maternal Mental Health will provide an holistic assessment, determine the severity of symptoms, and identify next steps including referrals for wraparound support.

This referral form must be completed by a clinician (eg. GP, midwife, nurse, HIP, Social Worker) or community agency. This referral is for those that would not otherwise be able to afford paid services. For paid services, mothers can book with our counsellors directly at this link

Mothers Helpers keeps all of the information that is completed below in a confidential file that only our counselling team can access.

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
Mother's Full Name*
First Last
Does this mother have a Community Services Card?*
- Yes
- No
Reason for referring for fully funded (free) appointment
Date of birth*
DD slash MM slash YYYY
Ethnicity*
Mother's Email*
Enter Email Confirm Email
Mother's Home Phone
Mother's Mobile Phone*
Mother's Address*
Street Address Address Line 2 City ZIP / Postal Code
Mother's GP*
Name of Mother's Midwife (if applicable)
Names and Date of Birth of children in their care*
Are they interested in attending a PND Recovery Course?*
Are they interested in attending a Preparing for Parenthood Course*
Are they wanting individiual counselling?*
Where did you hear about Mothers Helpers
Comments/Anything Else?
Please enter your name, designation, organisation and contact email below:
Consent*
- Has this mother given her consent to be contacted by us
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