• Please make you have read the M-TLC patient information leaflet (link needed), which provides further details about the service and whether it will meet your needs. The leaflet also provides email and telephone contact details for the service, should you require any further advice / support with making a referral.
  • Please be aware that the Maternity Trauma and Loss Care Service is not an urgent / emergency service.  If help is required urgently, please contact the relevant Mental Health Single Point of Access, which is open 24 hours a day, 7 days a week, 365 days a year:
    • If resident in Ealing, Hounslow or Hammersmith & Fulham: West London NHS Trust Mental Health Single Point of Access on 0800 328 4444.
    • If resident in Brent, Harrow, Hillingdon, Kensington & Chelsea or Westminster: Central & North West London NHS Foundation Trust Single Point of Access on 0800 0234 650.

Section one - consent

Required
Required

Section two - referrer details

Required
Europe/London
Required
Required
Required
Required
Required

Section three - patient details

Required
Required
Europe/London
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required

Section four - reasons for referral

Required
Required
Required
Required

Section five - obstetric details

Europe/London
Europe/London

Section six - other professionals involved

Section seven - safeguarding and risks

Required
Required