Mums Matter Referral Form

Referrer

First Name

Last Name

Phone Number

Your Contact Details

Your contact details will be held on Manchester Mind's database, which can only be accessed by current Manchester Mind staff.. We will not share these with any other organisation. We will use these details if there is an issue with the referral (e.g. we cannot make contact with the young person, or we need further details about their situation), a member of Manchester Mind staff may contact you for more information. For more details of how we hold personal data please see our Data Privacy Notice.

Who is this referral from?

Referring Organisation

Organisation Name

Address Line 1

Address Line 2

Address Line 3

Town/ City

Postal Code

Phone Number

Is this person aware that a referral is being made on their behalf, and that their details are being shared with Manchester Mind's Mums Matter Service?

We will use the details in this form to contact the person and arrange an assessment meeting with them. Please make sure they are aware this will happen before proceeding with this referral.

Please make sure the person is aware Manchester Mind will be in contact with then before continuing with this referral.

Mums Matter- Eligibility

The Mums Matter service is open to Mums with children under two, who live in Manchester

Is this person a Manchester Resident?

Yes

Don't know

Age of youngest child

We cannot accept Mums from outside of Manchester into this service.

Mum's Details

First Name

Last Name

Address Line 1

Address Line 2

Address Line 3

Town/ City

Postal Code

Please leave at least one phone number or an email address for the Mum. We will use these details to contact them about their referral.

Mobile

Phone

Referral Details

Local Children's Centre

What would you like Manchester Mind to help you with?

What is Mum's situation? What would you like Manchester Mind to help with?