• Please make you have read the service webpage, which provides further details about the service and whether it will meet your needs. 
  • 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.
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Section one - personal information

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What is your preferred method of contact? Required
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Can we leave voicemails on this number? Required
Can we text you on this number? Required
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Do you need an interpreter? Required
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Section two - GP information

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Section three - pregnancy/postnatal information

Are you pregnant, or the parent of a child below the age of 12 months? Required
If you are pregnant, where are you receiving care? (if known)

Section four - Further Information

What is the main concern that you would like help with? (please tick as many that apply) Required
Please indicate if you are experiencing any of the following: Please go straight to next section if main self-referral reason is severe fear of childbirth and no previous experience of pregnancy
How have you felt in the past month? (please tick as many that apply to you)
Are you currently, or have you recently been, receiving treatment for these difficulties?
Are you currently taking any medications?