Test Request form safe start

The Safe Start program is for women who are admitted to your maternity unit after the birth of their baby and it has been identified that they don't have the basic items to care for their baby once discharged.

Please note that orders placed before 10am may be distributed the same day if stock is available but delivery cannot be guaranteed.

If you are not yet registered, please register here before completing this form.

Social worker full name*

Hospital name*

Social worker email*

Social worker phone number (direct line preferable)*

example: 0744445555

Mother's full name(to prevent duplication of orders, for example: Jane Doe)*

Does the family have a health care card?*

Is DHHS involved with this family/child?*

Has this family been affected adversely by COVID-19?*

Is this family connected with other support services? If so, who?

What Local Government Area does the family live in?*

Does this family identify as Aboriginal or Torres Strait Islander?*

What are the causes of disadvantage for this family? (you may select multiple items by holding down your cntr or command key)*

What is the birth date of the baby (Please write dd/mm/yyyy)

Number of babies (if multiple birth)

Baby's gender?*

Expected discharge date of baby*

Delivery details for this order. Full address of hospital, including department*

Does the family require a portacot?*

Does the family require a pram?*

Does the family require a car restraint?*

Note - If the family needs two car restraints please detail this in notes below.

What clothing bags do they need? (you may select multiple items by holding down your cntr or command key)

Do they need linen or bedding?*

Have these goods been given to your client from the St Kilda Mum's stock on hand at your hospital?

Any further notes or comments (please include number of items for multiple children)

Does the family understand that for future material aid that they will need to access St Kilda Mums via a social worker or Maternal Child Health Nurse? (If they are not supported by another agency please link them into their local Maternal & Child Health Centre)*