Referrers Information

We have temporarily suspended applications from the following boroughs, any applications made will be rejected:

Barking and Dagenham
Barnet
Brent
Enfield
Haringey
Harrow
Islington
Kingston upon Thames
All boroughs East London
All boroughs South London

If you experience any trouble with the form or have language difficulties, please contact our AngelBox team on 0204 551 8540 - Option 0.

Eligibility Reminder

Please take this opportunity to check if your family is eligible for an AngelBox.

This does not include residents that are being temporarily housed from eligible boroughs, but evidence will be required from the parent/family during the assessment process.

Have you checked our eligibility criteria?

Yes

No

Is the parent or partner currently residing on a

Are any of the parents company directors, registered on companies house?

Does the parent or family reside in any of these boroughs? If so, please note that AngelBox deliveries are currently suspended except for exceptional cases which have special circumstances.

Is the baby born or due within the next 2 months?

Yes

No

Please confirm the following statements are true.

The referrer has checked that the total household income is below £16,000 per annum

The referrer acknowledges that any referral made for a newborn where the EDD is longer than 30 days away will automatically have their referral placed in our waiting list

Referrer Information

Please only apply if you have either a .gov.uk or NHS domain email

This section covers your details and professional credentials.

Referrers First Name

Referrers Last Name

Your email Address

What is the referring organisation

Your telephone number

Your job title

Health Survey about Individual

We're just collecting basic information about your recent engagements with the GP, Hospital or pharmacy as well as if you've seen our recently updated online health & wellbeing hub which has useful guidance and information on relevant NHS services and more.

Please can you fill out the following questions before continuing with this application.

Your time is appreciated.

Is the parent present?

Yes

No

Your child/childrens general vaccination history

Just a quick survey to better understand what vaccinations the children have taken previously and if there aware

Client/Patient Information

Please check if the parent or family meet our eligibility criteria before continuing with this referral.

This section of the form must be filled and include the parents personal information, contact details, financial circumstances and any other information which can help our assessors prioritise your referral.

Date / Time Last Visited Parent

Is the family/beneficiary aware, you are applying for an angelbox

Have you referred the family/beneficiary before

Clients First Name

Clients Last Name

Clients Email

Clients Phone/Mobile

Clients Date of Birth

Clients Marital Status

Clients right to live & work in the UK

Clients Benefit Status

Employment Status

Client/Patients Native Language

Partners First Name

Partners Last Name

Partners Date of Birth

Partners right to live & work in the UK

Do they live at the same address?

Partners email

Partners employment status

Clients Delivery Address

Building Name & Main Address

Postal Code

If known, Is this residence

Please explain their current financial circumstances

Additional private notes on clients to support their referral

Information about the newborn & AngelBox items

To be eligible for an AngelBox the newborn or toddler must be no older than 24 months.

Please fill out all the necessary information about the main beneficiary and what baby essentials or equipment is needed.

Is this referral for a

No. of Beneficiaries

Expected Due Date

Baby's Date of birth

If Known, At which hospital did/will they deliver the beneficiary

Where would the main applicant like the AngelBox delivered?

If known, what is the gender of the baby

Does client have other children

Is there any additional information about any pregnancy or due date related issues we should be aware off?

What AngelBox items would most likely benefit the AngelBox beneficiary (All items are brand new)

Baby equipment to be considered (Max 3)

AngelBox Specification

Please make sure parent is with you when filling out this section of the application.

If any food items or equipment are selected, our assessors will verify these items with parents before approving your referral.

Clothing Size

Nappy Size (Pampers Only)

Bath Tub

Baby Toiletries

Blanket or Sleepbag

Wipes

Changing Mat

Hooded Towel & Sponge pack

Does the baby suffer from any allergies or medical conditions?

Yes

No

If yes, what are the allergies or medical conditions

Manual Breast Pump (0-6mths)

Baby Bottles 2pk, 3pk or starter kit

Milk Formula 2 x 800g/900g

Baby Bottle Cleaning Brush

Food Jars (6 months + only)

Fruit Pots (6 months + only)

Specials

Weaning Bib

Dietary Requirements

Porridge

Food Pack (Plates & Cutlery)

Sippy Cup

Baby equipment to be considered (Max 2)

Additional Notes

Consent & Authorisation to submit referral

I have informed my client/patient that their name, address and contact number will be shared with BHCIC to enable an assessment of the baby items &/or equipment required.

I understand, and have explained to the family that that the information I have referred on this application form will be stored by Basch Helps CIC and may be used for impact reporting, monitoring and evaluation.

We aim to contact parent/family shortly after submission.

In your opinion, how urgent is this AngelBox referral?

High Priority (Baby Born)

Medium Priority (Baby EDD in 0-1 Months)

Low Priority (Baby EDD in 2-3 Months)

I have read and agree to our Referral Policy

I have read and agree to the Terms and Conditions and Privacy Policy

I agree for Basch Helps CIC to contact me and to process the information obtained in this application for the purpose of progress updates, reporting and any client related queries that may arise

Your Full Name

Time & Date of Referral

AngelBox Professional Referral Application