Referral form

REFERENCE FOR INCLUSION IN THE PROGRAMME

(Completion of the application form is optional)

Please complete the referral form and send it to info@mazisoumama.com, including the full name of the pregnant woman or mother being referred in the subject line.

Referrer’s details (To be completed by the referring professional)

Full name

Organization

Specialty

Phone number

E-mail

Referral details (Details of the person being referred)

Full name

Date of birth

Week or Month of pregnancy

Expected date of delivery

Date of delivery
(if already given birth)

I have informed the pregnant woman/mother about the MaMa programme and I am referring her to you for the following reason:

Criteria for Participation

Pregnant women, regardless of the stage of pregnancy.
Mothers, up to the end of the first year after childbirth.

Participation is available to pregnant women and mothers who are at least 18 years old
(minors must be represented by a parent or legal guardian).

Priority is given to pregnant women and mothers who:

have no income or are living at or near the minimum wage threshold, as defined by the relevant authorities.
are first-time mothers or are in the postpartum period.
lack family support or belong to single-parent families.
face difficulties entering or re-entering the labour market.

Date

Signature

Referral form

REFERENCE FOR INCLUSION IN THE PROGRAMME

Referrer’s details (To be completed by the referring professional)

Referral details (Details of the person being referred)

Criteria for Participation

I prefer to download the Referral Form