Sign up for our FREE 10-week programme, open to new mothers living in the London Borough of Southwark experiencing low mood, feelings of stress, anxiety and social isolation with babies aged 0-9 months.

Sessions start in October 2024 (Peckham Rye & Bermondsey) for 10 weeks – Date/Time TBC.

Completing this form is the first step to attending a Breathe Melodies for Mums programme. Once submitted, you will hear from one of our team who will provide guidance on next steps as well as answer any questions you may have.

If you require help completing this form or would like to receive it in a different format please contact us on or 07511 214 069.

We look forward to hearing from you!

Personal Details

All fields are mandatory, please complete the form in full to ensure your registration is processed as quickly as possible.

Mother's Full Name: Confirm Mother's Full Name: Mother's Date of Birth: Mother's Age (select from dropdown): Mother's Ethnicity (select from dropdown): Mother's Sex (select from dropdown): Baby's Full Name: 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 Gender: Email: Confirm email: Telephone: Flat / House Number & Street: Postcode:
Borough of Residence: Emergency Contact Full Name: Emergency Contact Number: GP Practice: GP Contact Number: Recruitment Method: (select from dropdown) Other, please specify: Please select your preferred session: 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) If you answered yes to the question above, please give detail below:

Would you like to sign up to our newsletter?
Yes, please sign me up.

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.