Lactation Support Clinic Referral Form
Birthworkers of Color Collective is proud of offer no-cost lactation support and education to our communities. Virtual and In-person support options available. Please note, our lactation support program is a teaching program led by experienced IBCLC with lactation students. Lactation students are in training to complete their IBCLC and will co-lead support sessions and review client referrals under the supervision of IBCLC's.
Who is completing this form?
Provider office
Parent
Doula/Birthworker
Community Organization
Other
Name of Healthcare Provider/Referring Organization
Provider/Organization Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Information
Reason for Referral/Support
Latch difficulties
Cracked/Bleeding Nipples
Low Milk Supply
Baby Not Interested
Sore Nipples/Nipple pain
Breast Pain
Baby not getting enough
Baby losing weight
Tongue Tie
Sleep difficulties
Pumping/Return to Work
Other
Any additional information we should know?
Family Information
Mother/Lactating Parent's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
City of Residence
Do you have health insurance?
Yes, Medicaid
Yes, Private/Employer Insurance
No
Not sure
Insurance Plan Name
Ex. Kaiser, LA Care, Healthnet, Blue Shield, etc
Baby Name
First Name
Last Name
Infant Date of Birth
-
Month
-
Day
Year
Date
How many weeks gestation was baby born?
Pre-term (before 37 weeks)
Full-term (37-42 weeks)
Infant Weight at Birth
Infant Current Weight
Please select how you would like to receive support?
Our lactation support team is available the 2nd and 4th Friday of every month at our Long Beach office for appointments and walk-ins, in-person and virtually. Please select the type of visit you would like and which dates work best for you?
Appointment Location
In-Person
Phone Call
Zoom
Can you attend at our next lactation support clinic date (virtual or in-person)?
Friday, April 10 10am-12pm PST/1pm-3pm EST
Friday, April 24 10am-12pm PST/1pm-3pm EST
Friday, May 8 10am-12pm PST/1pm-3pm EST
Friday, May 22 10am-12pm PST/1pm-3pm EST
Other
If you need an urgent appointment, please let us know when is the best time to contact you
Acknowledgement
Please note, our lactation program is a teaching program led by experienced IBCLC with lactation students. Lactation students are in training to complete their IBCLC and will co-lead support sessions and review client referrals under the supervision of IBCLC's.
Submit
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