Acacia Family Support | Postnatal Depression Support Services | Young Parents | Group Work

All fields highlighted in red are mandatory.

YOUR DETAILS
First name:
Last name:
Address:
Address line 2:
Town/City:
Post code:
Date of birth:
Email address:
Tel/Mobile number:
1st Child's name:
1st Child's date of birth:
2nd Child's name:
2nd Child's date of birth:
3rd Child's name:
3rd Child's date of birth:
We like to celebrate birthdays at our group! Please let us know if you DO NOT wish this to happen:
	Yes, I wish to celebrate my birthday No, I don't wish to celebrate my birthday
What are you hoping to get out of this group?:

Which topics or activities would you like to explore here? E.g. housing, arts and crafts, etc.:

SHOULD ANYTHING HAPPEN TO YOU WHILST YOU'RE AT THE GROUP WE NEED THE FOLLOWING DETAILS
Emergency contact (relationship):
Name:
Phone number:
GP Name:
GP Address:
Please detail any other agencies you're working with: (e.g. Forward Thinking Birmingham):

CONFIDENTIALITY
I understand that all the information I share will be held in the strictest of confidence. However, if I share anything that suggests I or others may be at any risk, I understand that we have a Duty of Care to break confidentiality and share information with relevant professional agencies. This may include my GP, Midwife, Health Visitor, Family Support Worker, B'ham Healthy Minds, Forward Thinking Birmingham etc.:
	Yes, I accept this No, I don't accept this
DATA PROTECTION - HOW WE WILL USE YOUR INFORMATION
In order for us to help you we need to gather, record and store your details in a confidential database. These details may contain your personal and sensitive or 'special' data. To comply with data protection legislation, we must tell you how we use and store this data and your rights concerning it. This information is contained in paragraph above. The record of your case will be stored in a shared electronic case management system accessed by authorised staff and volunteers of Acacia Family Support to record your contact with the service. Paper copies of your data will also be stored securely and destroyed when either you turn 24, your child is 2 or you stop coming to group before then. We may use some of your information to produce demographic reports to funders. When doing this all identifying information is completely removed so that it is completely anonymised.
Please tick to confirm that you have read and understood the privacy notification.
	Yes, I accept
SMILE! ARE YOU READY FOR YOUR CLOSE UP?!
As this group is new and exciting, we would like to take some pictures of you and your child(ren) participating in the group. If this is ok with you, please read and sign below: I give you all the permissions you need to copy, print, exhibit, transmit, and broadcast the contribution in all countries in the world by all means and, in all media, including the internet and social media channels. This consent includes, but is not limited to:
	(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and my child(ren) and/or record my and my child(ren)'s voice(s); (b) Permission to use my and my child(ren)'s name(s); and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, on television, radio and electronic media, and in educational/awareness raising media.
Consent is given in perpetuity and does not require prior approval by me. Please select below.
	Yes No
	SUBMIT >

ABOUT

Dads / Partners

HELP & SUPPORT

FUNDRAISING

VOLUNTEERING

BAME

YOUNG PARENTS

YOUR STORIES

NEWS

Group Work

Young Parents Group Work Registration Form

If you live in Birmingham and need help?

If you live outside of Birmingham and need help?