Maternity Trauma and Loss Care Service Self-Referral Form :: Central and North West London NHS Foundation Trust

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Date referral form was completed

Section 1: Personal information

First name * Required

Surname * Required

Date of birth * Required

Full address and postcode * Required

Which borough do you live in? * Required

Not eligible

Unfortunately, as a North West London (NWL) service we're only able to offer care to women and birthing people who live in one of the eight NWL boroughs.

If you live in any other borough please speak to your GP, your maternity service or for NHS talking therapies, you can find your local service here.

What is your preferred method of contact? * Required

Email

Phone

Text

Your email address * Required

Confirm your email address * Required

Your phone number * Required

Can we leave a voicemail? * Required

Yes

No

Can we send you SMS messages? * Required

Yes

No

What is your ethnic origin? * Required

Do you need an interpreter? * Required

Yes

No

If yes, in what language? * Required

Section 2: GP information

Can you provide your GP details? * Required

Yes

No

GP surgery name * Required

GP address

Do you consent to share info with your GP? * Required

Yes

No

Section 3: Support needs

What is the main concern that you would like help with? * Required

We appreciate one or more may apply, please pick the one you feel you most need help with. You will be able to share more of your concerns later in this referral process.

Severe fear of pregnancy and/or child birth (Also known as Tokophobia)

Baby loss/pregnancy loss, including termination for any reason

Traumatic experience during pregnancy, birth or after birth

Severe Fear of pregnancy and/or child birth (Tokophobia)

Are you currently pregnant? * Required

Yes

No

Do you have previous experience of pregnancy? * Required

Yes

No

Have you given birth in the last 12 months? * Required

Yes

No

Not eligible

Unfortunately, we are only able to offer care to women and birthing people who gave birth within the last 12 months.

Please speak to your GP regarding alternative support options. For psychological support, you can make contact with your local NHS talking therapies service. You can find your local service here.

If you wish to speak to a member of our team please contact us on:

West London Maternity Trauma and Loss Care Service: 0203 313 2022
Central North West London Maternity Trauma and Loss Care Service: 020 7685 6384

Do you know your estimated delivery date? * Required

Yes

No

What is your estimated delivery date? * Required

Where are you receiving maternity care? * Required

Please note that as a North West London (NWL) service, we are only able to offer care to women and birthing people who are booked for their maternity care at one of the six North West London maternity hospitals.

Please indicate if you are experiencing any of the following: * Required

Flashbacks (seeing images of a scary event replaying over in your mind)

Feeling as if something bad is about to happen

Avoiding things that remind you of an upsetting event

Feeling more sad or angry than usual

Confusion or memory blanks

Nightmares

Feeling very anxious

None of these

Do you feel able to share any more detail about your fears? * Required

This question is optional: Your answer will not affect your referral

Yes

No

Please provide details of your fears here: * Required

Not eligible

Unfortunately, as a North West London (NWL) service, we are only able to offer care to women and birthing people who are booked for their maternity care at one of the six North West London maternity hospitals.

If you have booked at any other hospital, please speak to your GP or your maternity team. For psychological support, you can make contact with your local NHS talking therapies service. You can find your local service here.

If you wish to speak to a member of our team please contact us on:

West London Maternity Trauma and Loss Care Service: 0203 313 2022
Central North West London Maternity Trauma and Loss Care Service: 020 7685 6384

Baby loss/pregnancy loss, including termination for any reason

Was your most recent baby loss / pregnancy loss, including termination for any reason, within the last 12 months? * Required

Yes

No

Are you currently pregnant? * Required

Yes

No

Not eligible

Unfortunately, we are only able to offer care to women and birthing people who experienced baby/pregnancy loss within the last 12 months.

Please speak to your GP regarding alternative support options. For psychological support, you can make contact with your local NHS talking therapies service. You can find your local service here.

If you wish to speak to a member of our team please contact us on:

West London Maternity Trauma and Loss Care Service: 0203 313 2022
Central North West London Maternity Trauma and Loss Care Service: 020 7685 6384

Do you know your estimated delivery date? * Required

Yes

No

What is your estimated delivery date? * Required

Where are you receiving maternity care? * Required

Please note that as a North West London (NWL) service, we are only able to offer care to women and birthing people who are booked for their maternity care at one of the six North West London maternity hospitals.

Please indicate if you are experiencing any of the following: * Required

Flashbacks (seeing images of a scary event replaying over in your mind)

Feeling as if something bad is about to happen

Avoiding things that remind you of an upsetting event

Feeling more sad or angry than usual

Confusion or memory blanks

Nightmares

Feeling very anxious

None of these

Do you feel able to share any more details about your loss? (Your answer will not affect your referral) * Required

Yes

No

Please provide details about your loss here: * Required

Not eligible

Unfortunately, as a North West London (NWL) service, we are only able to offer care to women and birthing people who are booked for their maternity care at one of the six North West London maternity hospitals.

If you have booked at any other hospital, please speak to your GP or your maternity team. For psychological support, you can make contact with your local NHS talking therapies service. You can find your local service here.

If you wish to speak to a member of our team please contact us on:

West London Maternity Trauma and Loss Care service: 0203 313 2022
Central North West London Maternity Trauma and Loss Care service: 020 7685 6384

Traumatic experience during pregnancy, birth or after birth

In the last 12 months, have you experienced trauma, before, during or after birth or in your maternity journey? (e.g. difficult pregnancy, postnatal care, unexpected caesarean or difficulties breastfeeding) * Required

Yes

No

Are you currently pregnant? * Required

Yes

No

Not eligible

Unfortunately, we are only able to offer care to women and birthing people who experienced a trauma in their maternity journey within the last 12 months.

Please speak to your GP regarding alternative support options. For psychological support, you can make contact with your local NHS talking therapies service. You can find your local service here.

If you wish to speak to a member of our team please contact us on:

West London Maternity Trauma and Loss Care Service: 0203 313 2022
Central North West London Maternity Trauma and Loss Care Service: 020 7685 6384

Please indicate if you are experiencing any of the following: * Required

Flashbacks (seeing images of a scary event replaying over in your mind)

Feeling as if something bad is about to happen

Avoiding things that remind you of an upsetting event

Feeling more sad or angry than usual

Confusion or memory blanks

Nightmares

Feeling very anxious

None of these

Other

Please provide details of your symptoms * Required

Do you know your estimated delivery date? * Required

Yes

No

What is your estimated delivery date? * Required

Where are you receiving maternity care? * Required

Please note that as a North West London (NWL) service, we are only able to offer care to women and birthing people who are booked for their maternity care at one of the six North West London maternity hospitals.

Do you feel able to share any more detail about your traumatic experience? (Your answer will not affect your referral) * Required

Yes

No

Please provide details about your traumatic experience here: * Required

Not eligible

Unfortunately, as a North West London (NWL) service, we are only able to offer care to women and birthing people who are booked for their maternity care at one of the six North West London maternity hospitals.

If you have booked at any other hospital, please speak to your GP or your maternity team. For psychological support, you can make contact with your local NHS talking therapies service. You can find your local service here.

If you wish to speak to a member of our team please contact us on:

West London Maternity Trauma and Loss Care service: 0203 313 2022
Central North West London Maternity Trauma and Loss Care service: 020 7685 6384

How did you hear about us? * Required

Google search

NHS professional referral

Word of mouth

SHOUT/HUG text service

Social media advertisements

Other

If 'Other', please list * Required

Maternity Trauma and Loss Care Service Self-Referral Form

Click this bar to read important information before completing referral form

Section 1: Personal information

Not eligible

Section 2: GP information

Section 3: Support needs

Severe Fear of pregnancy and/or child birth (Tokophobia)

Not eligible

Not eligible

Baby loss/pregnancy loss, including termination for any reason

Not eligible

Not eligible

Traumatic experience during pregnancy, birth or after birth

Not eligible

Not eligible

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