Healthy Mothers, Healthy Babies Referral Form CC-147-03

Healthy Mothers, Healthy Babies Service Referral

HMHB Service Description from website 01/05/2026

All Referrals are Confidential

Please complete as many details as known, the fields marked with a * are mandatory.
If you need help completing this referral, please contact the Healthy Mothers Healthy Babies Support Worker on 0417 509 415.

What is your relationship to the client being referred? *

Please specify

Does the Client live in Victoria? *

YesNo

Unfortunately, this service is only available for Victorian residents, please contact the Healthy Mothers, Healthy Babies Team on 0417 509 415 to discuss other services available or visit Our Website to explore our other services available.

Referrer Details

First Name *

Last Name *

Contact No. *

Email Address *

Organisation Name & Address

Does the referred client give consent for this referral to be sent to Gateway Health? *

YesNo

If the referred client is under the age of 15, does the Parent/Guardian consent for this referral to be sent to Gateway Health? *

YesNoN/A

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Contact No.

Referral Details

Reason for Referral - Please give as much detail as possible *

Are there any Risk or Safety Concerns?

Please provide further details

If currently pregnant what is the estimated due date to give birth?

If recent delivery what was baby's the date of birth?

Client's Registration Details

First Name *

Last Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Sex assigned at Birth *

Contact No. *

Email Address *

Home Address *

Street address *

City *

State *

Postcode *

Please provide details of preferred safe contact method

First Nation Status *

Name of Mob

Does the client identify as LGBTQIA+?

YesNoPrefer not to say

How should we record the clients Gender Identity?

Do you identify as LGBTQIA+?

YesNoPrefer not to say

How would you like us to record your Gender Identity?

Country of Birth *

Refugee or Asylum Seeker

YesNo

Year Arrived

Main Language spoken at home *

Interpreter Required?

Are there any needs/preferences that would assist Client/Baby with accessing the service?

Household Details

Living Arrangements *

Please specify

Accommodation Setting *

Please specify

How many children are in the household? *

Please provide child's/children's age and gender

Emergency Contact Details

Full Name *

Contact Number *

Relationship to Client *

Relationship to You *

Intake Contact Details

Thank you for completing this referral, we will contact the referred client to discuss the next steps regarding this referral.

Thank you for completing this referral, we will contact you to discuss the next steps regarding this referral.

Please indicate a preferred day and time to make contact

Referrer's Signature *

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Referral Date *

Your Signature *

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Referral Date *

For further assistance with this referral please contact the Healthy Mothers, Healthy Babies Support Worker on 0417 509 415.

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