Virtual Infant Feeding Support Request Form Sophie Burrows IBCLC

If this form doesn’t load below, please email me at: sophie@theboobladyibclc.com and I will be in touch asap.

Birth Parent Full Name *

Please indicate your preferred name and your pronouns (she/her/ they etc).

Name of supporting person also present in the consultation

Name of partner, dad, supporting adult

If you have any additional needs, please let me know, and I will do what I can to help you during the consultation.

For example: Physical disability or neurodiversity. (Dyslexia, ADHD etc)

Baby full name *

Please enter your own if baby doesn't yet have a name

Email *

Mother date of birth *

Baby date of birth *

Baby current age *

Baby Sex *

Female
Male

How long do you plan to breastfeed for?

How did you find out about my services? *

Contact number *

Home Address *

Please include postcode

Hospital used for birth *

Or hospital to report to if you had a home birth

Midwife or health visiting team *

Method of birth *

Please also list here if you received fluids and medication/pain relief during birth.

Length of labour *

How many weeks gestation was baby at birth? *

Per 24 hours, how often if your baby feeding? *

0-8 times
8-12 times
12-20 times
Not currently breastfeeding

Previous breastfeeding experience? *

Yes, successful
Yes, with problems
No

Does your baby have any weight related concerns? *

If yes, please give description below. Include all weights recorded from birth with dates in Kg.

If yes, please give a description

Is birth parent or baby taking any medication, including in the past week?

Please indicate who and what.

Has the birth parent had any surgery or biopsy of their breast/chest?

Any health concerns related to birth parent or baby?

Please indicate preferred upcoming date for appointment. *

This is dependent on Sophie's availability. There are occasions that Sophie might be able to see you within hours of your booking request so please indicate your next available time.

Have you had a consultation with an IBCLC before? *

If yes, please give some information as to why. *

Please give a description here of the reasons you are requesting a consultation. *

Please indicate anything you've already tried.

Please indicate any additional questions here.

This service is £85. I will send you an invoice before the consultation. The consultation is an in-depth overview of the situation, the virtual support session can take over an hour and I don’t time myself; I am here to support you and sometimes that can take time. I will do a written report after to send you with links to your particular situation to support you with the issues you are experiencing. On average I spend 4+ hours per client with report writing, ongoing support etc. Payment is due before the consultation can commence. Thank you for your understanding. *

Understood and Agreed

In accordance with GDPR 2018 you must be informed what Data will be requested from you, how that Data will be processed or shared and what your rights are in relation to that Data. I will only request information that she needs in order to provide her services effectively and safely. I will retain your consultation Data for a period of 25 years as per Government requirements. Your information will not be used for marketing purposes. The Data held about you will include name, age, address, email, your child’s name and date of birth, medical history, consultation notes, and may include a baby’s weight chart, care plan and a report to your GP. Information may be shared with your health professionals (see above). You have the right to request access to your personal Data. You also have the right to correction of that Data and deletion (where appropriate). If you are not happy with how your Data is managed, you have a right to complain. I reserve the right to contact you in the future regarding other services *

Agreed

Virtual Call Guidance- The video call will take place on a platform called “zoom” please download and familiarise yourself with it and its settings, I need to have you with a video and audio link, the room needs to be clear and you must not be lit from behind, lighting from the front is good. Please be dressed (although I am happy to talk with someone who is skin to skin with their baby, this rule is relaxed for those with the baby providing human contact) please make sure your family are dressed around you, partners/ dads are actively welcomed to join the consultation if possible as they provide a great deal of needed support and are a great asset to the consultation as their ability to retain information given can be a positive help to share the load of support. I do ask that the space the consultation is in is clear from distractions, please avoid others having phone conversations in the same room as it can be extremely distracting for everyone. I don’t not allow my consultations to be recorded by you in any shape or form without prior consent. If you are using a phone for the consultation please find a way of having your phone out of your hands and on a “stand” of some sort. There is usually something around the house we can use to do this. Please try and set this up so you can ideally be on your sofa or bed there will likely be moments where you need to move the camera closer to you for observation of breastfeeding so bear this in mind, this is another reason having partner/dad on hand will be of use. If you find between answering the questions on the form and the consultation that the situation has changed, please email me or if not enough time to do so please address this at the beginning of the consultation so I have all the needed information to help you *

Agreed

Our Contract: I am requesting and give consent for a breastfeeding consultation with an International Board Certified Lactation Consultant for myself and my infant/s. The consultation will include but not be limited to a visual examination of my breasts as well as an observation of a breastfeeding session. While advice given by Lactation Consultants is effective in most instances, I understand that these recommendations may not completely remedy or prevent adverse symptoms. The success depends, in larger part, on my follow-through with the recommendations. • I understand that a partial or follow-up visit/call is sometimes necessary. • I understand this consent it for in-person visits, as well as phone conversations, and any information sent/ communicated by e-mail, mobile phone, fax, SMS text messages, and/or private social media. I understand electronic/ cellular forms of communication may not be encrypted/ secure. • I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations. • I understand that my doctor is my primary health care provider and that he/she is responsible for the overall care of my infant/s. I will receive written recommendations at the end of this visit. A copy of the recommendations may be sent to my doctor for his/her information. I indicate with my agreement below that I agree to this. • I give consent for the lactation consultant to use clinical information and any photographs obtained during our sessions for conferring with other health care providers and education of mothers about lactation. I won’t be identified in any way, but aspects of my situation may be described and discussed. • I understand it is my responsibility to call/ communicate to the lactation consultant with progress reports, questions or concerns. • I understand that charges for this consultation will be payable in a timely manner when requested by the lactation consultant • I understand that for this lactation consultation and all follow-ups, the lactation consultant will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners and the Standards of Practices of the International Lactation Consultant Association. • I understand that video calls are not the most ideal way to support but if circumstances mean they are the only option the Lactation Consultant will support in the best way they can. I understand that the Lactation Consultant is restricted in this case because of inability to perform a full observation or oral check on the infant. • I understand that the lactation consultant reserves the right to add and amend this contract as they learn more about the practicalities of video consultations. •I understand that the Lactation Consultant may be interrupted during any video consultation with family in their home or needing to answer the phone or door but the lactation consultant will strive to make that as unlikely as possible but when agreeing to book a consultation I understand this is a possibility. •I understand that the Lactation Consultant will be prompt to the Video call and I should be too. *

Agreed

Website

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Jessica Oversier

11:00 11 Feb 22

Sophie is full of passion and knowledge! It was very reassuring being able to chat to Sophie about all things breastfeeding and what to expect once the baby is here. For anyone who needs a little bit of support and/or guidance, Sophie is amazing and she'll definitely help put your mind at ease. Thank you so much Sophie, I look forward to speaking again soon!

Sophie Lavender

20:21 30 Jul 21

Where to begin.. we had a zoom consultation with Sophie this afternoon and her passion is infectious! The things we have learnt and that have been highlighted to us was done is such a personalised way we know will be rememberable. Talking through things we didn’t know we needed to know and topics that opened our minds. If anyone is thinking about booking Sophie don’t think just book! Sophie arranged our meeting within hours! We are expecting our baby soon and now feel much more equipped to start our breastfeeding journey. Out of all of the people we have had so far to guide us into parenthood Sophie is by far the most helpful, beneficial, passionate, knowledgeable and giving person we’ve found. Thanks again Sophie for everything and we’re looking forward to talking again soon! Sophie & Keith

Caroline Guigou

08:25 13 Apr 21

I cannot recommend enough Sophie. She helped me and my 7 weeks old girl after a bumpy start in breastfeeding (engorgement, poor attachment, mastitis, tongue tie, weaning of nipple shields). Her patience, professionalism and knowledge are invaluable.

CAROL ANDREA PREGONERO GAMEZ

13:35 04 Feb 21

I cant recommend sophie enough. I have a 2 month baby and we had been having issues with breastfeeding since he was born. Sophie quickly Assessed the issue and proposed a practical solution. She was kind and warm, and provided very helpful information .

Zsuzsanna Veszprémi

15:58 12 Aug 20

Phoebe Stockdale

11:32 23 Jan 20

Sophie is simply amazing!I have seen Sophie throughout my breastfeeding journey, since my baby was 4 weeks old and latest for advice on my return to work and my now 9 month old. She has been instrumental support throughout all the challenges that me and my little one have faced.Her knowledge really knows no bounds and every consultation she has been supportive and very informative, which also continues after the consultation as well.Sophie's calming nature and non-judgmental approach is so very reassuring and I really can't recommend her support enough!

Lauren Wong

18:05 24 Jan 19