• 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

Has the patient consented to this referral? Please note: Consent must be gained for the referral in order for it to be processed Required
Has the patient consented to information about this referral being shared with their GP? Required

Section two - referrer details

Required
Required
Required
Required
Required
Required

Section three - patient details

Required
Required
Required
Required
Required
Required
Can we leave a voicemail on this number? Required
Can we send text messages to this number? Required
Required
Can we contact the patient via email? Required
Required
Interpreter required Required
Required
Disability Required
Required
Required
Required
Required
Required

Section four - reasons for referral

What is the primary reason for referral? Required
Responses to traumatic experiences can be very varied. Below are some common responses. Please indicate if the patient is experiencing these: Please go straight to next section if main referral reason is primary Tokophobia
Has the woman received help for their mental health from any of the following in the past? Required
Has the patient experienced any of the following in the past? Required
Is the patient currently prescribed any medications Required

Section five - obstetric details

Maternity service

Section six - other professionals involved

Section seven - safeguarding and risks

Are there any current risks to children/ the unborn baby? Required
If yes, has a referral been made to children’s services? Required