Breastfeeding Referral Form

Form temporarily not available.  Please send email with your information to info@nursingmoms.org  

If you live in one of the areas that we service, and you wish to be counseled by Nursing Mothers, please submit this form.  Your referral form will received by a NMI counselor who will be in touch with you soon. Being counseled means that an NMI counselor will call you on a regular basis.  You may also call us toll-free at 866-733-4NMI or send an email question to info@nursingmoms.org for mother-to-mother support without getting a counselor.

 Our services are free-of-charge.   

Name

Phone Number

Address

Email Address

Your Doctor (OB) 

Baby's Doctor

Baby's Due Date or Birthdate

Baby's Place of Birth (or planned place of birth) 

Baby's Sex Male    Female

Sibling's Ages

Have you already been contacted by a Nursing Mothers Counselor?  Yes     No

            If yes, please list her name

Is this your first nursing experience?  Yes    No

Did you attend a breastfeeding class?  Yes    No

            If yes, where was the class?

Are you having any problems breastfeeding your baby?  Please explain.

Additional Comments