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Need Support? Make a Referral Today.

Mother, Baby, & Beyond’s HEAP Referral Form is a simple way to connect mothers and families impacted by substance and opioid use to compassionate, culturally grounded care. Whether you're referring yourself or someone in your community, this form helps us understand their needs and provide the right support. MB&B offers peer support, harm reduction resources, housing navigation, pregnancy supplies and more, for both clients and referring individuals who may also need services.

Individual Referral for Support Services

Date
Month
Day
Year
Referred by:
Self
Family Member
Organization
Other

Person Needing Support

Is the client currently pregnant or parenting?
Safe to Contact?
Preferred Method of Contact
SUD/OUD Risk Indicators (check all that apply)
Social Determinants of Health (check all that apply)

Type of Support Requested

Primary Concerns (check all that apply)
Looking for:
Current Needs (check all that apply)
Please note if services are being requested for:

Consent and Release

Can we follow up with you?

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