Please complete this form to register interest in our FREE 10-week programme, open to new mothers living in the London Borough of Southwark experiencing low mood, feelings of stress, anxiety or social isolation with babies aged 0-9 months.

You will be notified of new dates once they are confirmed, subject to funding.

If you need help completing this form have any questions please contact us on [email protected]

We look forward to hearing from you.

Personal Details


All fields are mandatory.

Mother's Full Name: Mother's Age: Mother's Date of Birth: What gender do you identify with? Which language do you speak mostly at home? What is your ethnicity: Baby's Date of Birth (Please note to be eligible for this programme your baby must be aged 9 months or younger at the start of the programme): Baby's name: Email: Confirm email: Telephone: Postcode: Borough of Residence: Name of GP Surgery: Person to contact in case of emergency for you: Emergency Contact Mobile number: Recruitment Method: (select from dropdown) Other, please specify: Do you have any access or support needs to ensure you can take part in this activity? (E.g. wheelchair access, captioning for online activity, large print information, sign language interpretation). We can provide financial support for travel if needed (e.g. taxis). If you answered yes to the question above, please give detail below:

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By submitting this form you are consenting to our privacy policy.
The data collected will be anonymised and shared with Southwark Council who are funding this programme for the purposes of reporting.