Regional request form

Thanks for visiting St Kilda Mums Rural and Regional Service.

To access our service, all social workers and Maternal and Child Health nurses must be registered with St Kilda Mums.

If you are not yet registered, please register as a regional social worker here prior to completing this form.

Please note, complete one form for each family you are requesting for. (Except for One Mother to Another orders - see below).

One Mother to Another Gift Packs for your clients. If you require multiple packs please fill in one request form - we don't require individual forms for each client in this case. In the 'Mother's Name' field please use 'OMTA' and note the number required in the One Mother to Another box on this form.

For helpful hints on how to complete this form please click here.   

For further assistance or for emergency requests, please contact the Regional Service Coordinator via email at regional@stkildamums.org

We look forward to receiving your request soon - thank you for supporting families in need.

Currently we are experiencing great demand for our service so we are asking that you explore all avenues for funding and brokerage before accessing our service. This includes any DHHS, NEP or your own agency brokerage.

Your Details

Your name *:


Delivery will be either to your office or to a freight depot nearby. Please provide delivery address (items will never be delivered directly to your client)*:

Family Information

Mother's full name or reference (to prevent duplication of orders, for example: Jane Doe)*
What Local Government Area does the family reside in? *
Does this family identify as Aboriginal or Torres Strait Islander? *
Does the family have a health care card? *
What are the causes of disadvantage for this family? (you may select multiple items by holding down your Ctrl or command key)*

You may select multiple items by holding down your Ctrl or command key. If you chose 'other', please detail it here

Is DHHS involved with this family/child?*

Is this family connected with other support services? If so, who?
What is the due date of the baby or the birth date of the youngest child? (Please write dd/mm/yyyy) *
Baby's gender? *
How many children are there in total in this family? (please include baby or babies due to be born) *
As of today how many children are younger than 12 months (including the one(s) due)? *
What the the age(s) and gender of the older siblings? (Please write G5, B6 etc.) *

 

Items Required

Cot: Does the family require one? If so, please enter 1 here (2 for twins)

If the family has a cot in good condition that complies with the current regulation and only needs a mattress, please enter 1 here , specify the details of the cot on notes and specify the required mattress size here (length, width and height). You should find these measurements on the base of the cot.

 

Pram: Does the family require one? If so, please enter 1 next to the type (one pram only)

Single Pram:
Stacker/Tandem Pram:
Side by Side Double Pram:
We try to match the best pram for the family, please indicate if they have a car or they rely on public transport and/or any details relevant for pram/stroller selection.

If the family needs a multiples pram please enter 1 and we will contact you to confirm the most suitable solution.
Triple: Quad:

 

Car Restraint: Does the family require one? If so, please enter 1 next to the type. If you need more than one car restraint (for siblings or multiples) please enter the relevant number next to the type.

Capsule (rear facing for infant):
Reversible (rear and front facing):
Toddler (front facing with harness):
Booster (front facing, no harness):

Nappies: If the family needs nappies, please enter the number of children you are requesting nappies for here and specify the sizes here . Note that wipes will be automatically allocated with any nappies provided.

 

Other Items: Please enter 1 next to the following items in case the family would need any. If they need more than one please enter the number but remember that many items come in packs or kits.

Baby Front Carrier:
Bath:
Breast Feeding Kit (includes manual breast pump):
Bottles (only available once baby is born):
Bouncer:
Breast or Maternity Pads Pack:
Change Mat:
Coats:
First Food Kit (utensils and equipment):
Formula (only available once baby is born):
Highchair:
Nappy Bag:
Safety Kit (drawer/cupboard locks, power point covers etc):
Sterilizer:
Toiletries Packs: Baby or Child , Adult , One Mother to Another
Toys Bags/Activity Mats/Books & Puzzle Bags:

 

Clothes: If clothes are needed, please enter the number of clothing bags on the size required. Please note that clothing bags contain 80-100 items.

Size Boy Girl
UniPrem:
Prem
Birth-1
1-2
2-3
3-4
4-5
5-6
7-8
9-10
10-12

 

Linen: If they need linen, enter the number of linen or bedding bags they need.

Cot Boy: Bassinet Boy:
Cot Girl: Bassinet Girl:
Cot Unisex: Bassinet Unisex:

 
Do you have any further notes or comments to make about this request?

We will notify you via email when your request is due for delivery.  (If you, a colleague or volunteer from your agency would ever like to collect requested items directly from our HQ in St Kilda please email regional@stkildamums.org to confirm a date for collection).


Please confirm that you agree with the terms of our Service Policy? *