LC Referral Form

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 part-time FREE Breastfeeding Information and Support Service that works with whanau to achieve their breastfeeding goals within an appointment-based setting. Our hours are Mon, Tues and Wed, 9am - 3pm
We offer FREE Community Lactation clinics to residents of the Midcentral Region whom require lactation and breastfeeding service, funded by Midcentral DHB.
Please note: We endeavour 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
Please google search for a full list of private Lactation Consultants (fees-apply)

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

* 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

Upload copy of client's note *

Max file size: 20MB

Reason for referral *

Mother's Name *

First

Last

Baby's Name *

Mother's Date of Birth *

Baby's Date of Birth *

Mother's ethnicity *

Baby's ethnicity *

Baby's Birth Weight *

Mother's Address *

Baby's current medication (if any) *

Are you rural? *

Yes

Home Phone: *

Mobile number: *

Mother's current medication (if any) *

Mother's Email *

Gestation when baby born or gestation of pregnancy at time of referral *

Where did you give birth? *

Mothers - Do you/have you had any significant medical issues? i.e. diabetes, thyroid, depression *

Symptoms: Has the referred had any of the following? *

Recent travel or contact with someone with novel coronavirus. a) Has the referred travelled to or from (excluding airport transit through) countries or areas of concern* within 14 days before onset of illness? *

Yes No

If selected YES, please give details below *

I agree to the information on this form being collected and used by Community 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.

b) Has the referred been in close contact or casual contact with a person with suspect, probable or confirmed infection of novel coronavirus in the 14 days before the onset of your symptoms? *

Yes No

If yes, please provide date of contact (dd /mm / yyyy). If No, then please enter 00/00/00 *

Please tick the appropriate box *

I the 'Person Referring Client' I the 'Client'

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 in 3 working days, please call us on 022 528 2466 so we can action your referral as quickly as possible.

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