Acacia Family Support - Support services for pre and postnatal depression and anxiety
Stars

Self referral

You can make a referral by completing the form below or calling us on 0121 301 5990 (Mon-Fri 9.30am-3pm). You cannot complete this form on behalf of someone else. You can access our service if:

  • You or your partner are pregnant
  • You have a child under the age of two
  • You live in Birmingham or you are registered with a GP in Birmingham (for dads and partners we also offer phone support for those who live or have a registered GP address in Solihull or Birmingham) 

Please note:

  • If you are a carer, relative or friend of the person, unfortunately we can’t accept a referral on behalf of someone else. We would encourage you to support the person to complete the online self-referral themselves, or they can call us on 0121 301 5990.

  • If you are a grandparent or other relative and you are seeking support for yourself, please don't use this form, instead use the contact us form.
  • If you are a professional making a referral, please complete the referral form – click here for agency online referral.

Please be aware, Acacia Family Support is not a crisis service. If you are currently experiencing distressing thoughts and feel you might be at risk of harming yourself or someone else, please click here to view a list of other appropriate services.

Once you have completed this form, we will contact you to either offer you an initial telephone assessment call or signpost you to the most appropriate service for your needs. If we are unsuccessful in reaching you over the phone, email or text, we will post a letter to the address provided on the form, requesting you to call us.

Referral criteria – Important:

In order for Acacia to provide you with a service you must be:
(Our dads'/partners' support service is available for dads/partners in Solihull as well as Birmingham. If you are a Solihull based dad/partner just click yes to answer the first question below. Unfortunately we don't support mums in Solihull at the moment.)
If you live outside Birmingham please click here to visit the Hearts and Minds national map of available support groups in your area.

IMPORTANT

Acacia has a duty of care to ensure you, and others are safe. Please note if you tell us anything that suggests you or someone else is at risk, this information will be shared with an appropriate agency.

Please note that information contained in this form will be stored and processed by Acacia as part of our legitimate interests. Full details are contained in our privacy notice click here to view. Please ensure that you are aware of this before submitting this form to us.

If you have had no contact from Acacia within 7 working days of returning your form, please contact the office on 0121 301 5990 to confirm receipt.

Personal details:

e.g. Miss/Mrs/Ms/Mr/Mx
We will contact you by all the methods of contacts you have provided.
e.g do not leave voicemail messages...text only etc.
eg. working days. This will help us when scheduling your call.
e.g learning difficulties, information processing difficulties, hearing issues, access problems etc. Please note, if we are able to offer an initial assessment, it will be conducted over the telephone. Please let us know how we can best support with this assessment.
The emergency contact is the person that we would contact in the case of an emergency
(if applicable)
(if applicable)
(if applicable)
If you have other children, please provide their details starting with the youngest to oldest:
Please select all that apply:
(Please give the details e.g. dates, name of organisation and any diagnosis) If yes, please specify: