Spoons Self Referral Form
Having a baby on the neonatal unit can be an overwhelming experience with varying outcomes. Some families can find it helpful to have someone to help them process their experience and navigate their journey.

This form can be completed by the parent or carer of a baby who is admitted to neonatal care in Greater Manchester. The information will be used by our Family Support Team to contact you via the telephone number provided to discuss how we can help you and your family, therefore please only complete this form if you are happy for us to contact you.

Further information about Spoons can be found on our website www.spoons.org.uk
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Email *
Your name *
Your address *
Your Date of Birth *
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Your contact telephone number *
Do you consent to us contacting you via the following methods? *
Required
Consent to leave voicemails *
How would you prefer us to contact you? *
Required
Do you consent to Spoons processing and storing your data for the purpose of this referral? (You can request to withdraw your consent at anytime please see our privacy notice for more information https://spoons.org.uk/privacy/ *
Please provide the name of someone we can contact in an emergency. *
Please provide a telephone number for your emergency contact as named above. *
What is your relationship to your emergency contact as named above?
Your baby/babies name/s?
Your baby/babies date of birth?
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Which neonatal unit/s have cared for your baby? *
Required
Is your baby still on the neonatal unit *
Which Language do you speak other than English?
Please tick any of the following services which you would like to learn more about
Do you have any other children? *
Please provide the name(s) of your other child/children
Please provide the age(s) of your other child/children
Can you briefly explain a little about your experience of neonatal care? *
Do you have any requirements which may support you when accessing Spoons? *
Do you have support from any of the following services? *
Required
Would you like to sign up for our newsletter? (If you sign up you can withdraw your consent at any time by clicking unsubscribe or contacting care@spoons.org.uk) *
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