WE DON'T LEAVE THE BREAST TILL LAST
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Breastfeeding
LC Referral Form
Community Lactation Clinic
Workforce Development
Peer to Peer
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Home
Breastfeeding
LC Referral Form
Community Lactation Clinic
Workforce Development
Peer to Peer
Contact
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YOUR CART
Breastfeeding Support
Here at Community Birth Services we believe in a supportive and safe environment for women and whanau who are going through pregnancy, childbirth, breastfeeding and their early days of adjusting to parenthood.
Community Birth Services is a FREE Breastfeeding and Lactation Information and Support Service that works with whanau to achieve their breastfeeding goals.
We offer FREE Community Lactation clinics to residents of the MidCentral Region who require breastfeeding and lactation support, funded by Midcentral DHB.
Please note
: We endeavor to support all referrals however there is a triage system put into place to support breastfeeding dyads that are more vulnerable or urgent.
Referrals can be made through our website at
www.communitybirthservices.org.nz
, via phone, email, through your health care provider or through our clinic.
Appointments are limited.
CBS Lactation Consultancy Service Referral Form
(
MidCentral Region
)
Please complete this referral form if you are a mum that needs breastfeeding support or you are referring a client that needs breastfeeding support
Referral information
*
Indicates required field
Name of Person Referring Client
*
Contact phone number of person referring client
*
Referee's Email Address
*
My client has given their permission for the CBS Lactation Consultant to contact them directly:
*
Yes
Reason for referral
*
Referred details
Mother's Name
*
First
Last
Baby's Name
*
Mother's Date of Birth
*
Baby's Date of Birth
*
Mother's ethnicity
*
Mother's mobile number:
*
Other phone number:
*
Baby's ethnicity
*
Baby's birth weight
*
Mother's email
*
Have you got weight history information?
*
If there is a history of baby's weight you would like us to know, please indicate that here.
Mother's address
*
Are you rural?
*
Yes
Baby's current medication (if any)
*
Mother's current medication (if any)
*
Mothers - Do you/have you had any significant medical issues? i.e. diabetes, thyroid, depression
*
Gestation when baby born or gestation of pregnancy at time of referral
*
Where did you give birth?
*
Palmerston North Hospital
Horowhenua Health Centre (Levin Hospital)
Dannevirke Hospital (THG)
Te Papaioea Birthing Centre
Home
Haven't birthed yet (i.e. antenatal)
Other
Another district hospital or birthing centre
Other information
Do you have any cultural, lifestyle or other preferences?
*
Yes
No
Maybe
If you have any cultural, lifestyle or other preferences, please provide further information:
*
Do you have a Community Services Card?
*
Yes
No
What is your household income?
*
Did not specify
$0 - $14,000
$14,001 - $48,000
$48,001 - $70,000
$70,001 +
Would rather not say
Is there anything else you would like us to know?
*
If there is anything else you would like us to know that we haven't asked please let us know here
Consent to share
Please indicate below if you consent to us sharing your breastfeeding and lactation care plan with your lead health care provider
Consent to share:
*
Lead Maternity Carer (e.g Midwife)
Well Child Provider
General Practitioner
Please tick where you provide consent
Lead maternity carer
*
Well child provider
*
General practitioner
*
Lead maternity carer email
*
Please complete if known
Well child provider email
*
Please complete if known
General practitioner email
*
Please complete if known
Covid 19 screening/declaration
Symptoms: Has the referred had any of the following (new or worsening)?
*
Cough
Sore throat
Shortness of breath
Runny nose
Temporary loss of smell
Fever (38 degrees or higher)
No, the referred has not had any of the above symptoms
1) Have they, or is someone they have had contact with, currently undergoing testing for COVID-19 and awaiting test results?
*
Yes
No
2) In the last 14 days, have they been in contact with others who have been unwell with respiratory symptoms or fever, or are suspected or confirmed to have COVID-19?
*
Yes
No
3) In the last 14 days, had international travel, had direct contact with a person who has travelled overseas, worked on an international aircraft or shipping vessel or cleaned at an international airport or maritime port or in areas/ conveniences visited by international arrivals?
*
Yes
No
If selected YES, please give details below
*
If yes, please provide date of contact (dd /mm / yyyy). If No, then please enter 00/00/00
*
Authorisation
Please tick the appropriate box
*
I the 'Person Referring Client'
I the 'Client'
I agree to the information on this form being collected and used by Communit
y Birth Services for reporting purposes only. Names will not be disclosed or passed on to any other organisations or people without the permission of the client named in the referral form giving their consent.
PLEASE READ CAREFULLY BEFORE YOU SUBMIT THIS FORM.
If you have completed this form correctly, when you press 'SUBMIT' you will receive a confirmation message on your screen. Please note you will not be sent a confirmation email. The form will not submit and you will not receive a confirmation on your screen if the mandatory information has not been completed, so please check the form again and submit.
If you have
not heard
from a member of our team, please call us on 022 528 2466 so we can action your referral as quickly as possible.
Submit
