Breastfeeding Support Referral Form - NYC.gov 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. This helps keep track of your referral.
3. Fill in the mother’s name and infant’s name in the designated fields. Ensure accuracy for proper identification.
4. Input the mother’s age, gestational age, parity, and birth weight. These details are crucial for healthcare providers.
5. Provide a contact number for the mother to facilitate communication.
6. Indicate if there is a history of breastfeeding by selecting 'Yes' or 'No'.
7. Complete the referral section by filling in the referring provider's name, title, address, and phone number.
8. Select the reason for referral from the options provided, ensuring you check all that apply.
9. Specify who the referral is directed to by choosing from lactation specialists or other services listed.
10. Finally, fill in appointment details including date, time, and contact information for follow-up.

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