Date Section 1 - Your details
Date of birth
Borough of residence
Can we contact you by email?
Can we leave voice messages on this number?
Can we send text messages to this number?
White - British White - Irish White - any other White background Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - any other mixed background Asian or Asian British - Afghani Asian or Asian British - Arabic Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Indian Asian or Asian British - Iranian Asian or Asian British - Iraqi Asian or Asian British - Japanese Asian or Asian British - Pakistani Asian or Asian British - Tamil Asian - any other Asian background Black or Black British - African Black or Black British - Caribbean Black - any other Black background Other ethnic group - any other ethnic group I do not wish to state Unknown
Can you tell us if you have any physical health conditions?
Section 2 – GP information
GP surgery name
GP phone number
GP surgery address
*Required Section 3 – Pregnancy and postnatal information
Are you pregnant, or the parent of a child below the age of 12 months?
If you are pregnant, when is your expected delivery date?
If you are the parent of a child below the age of 12 months, what is your baby’s name?
If you are the parent of a child below the age of 12 months, what is your baby’s date of birth?
Please also provide the name(s) and date of birth(s) of any other children you have
If you are pregnant, where are you receiving antenatal care? (if known):
Chelsea and Westminster
Independent / private
Other (please specify)
If you selected 'other' please tell us where you are receiving antenatal care
Section 4 – Further information
What is the main concern that you would like help with? (please tick as many that apply)
Severe fear of childbirth with no previous experience of pregnancy
Loss or bereavement
Other mental health concerns
If you would like help with ‘other mental health concerns’, would you be able to tell us more about what you are experiencing?
Please indicate if you are experiencing any of the following
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 more angry than usual
Confusion or memory blanks
Feeling very anxious
None of these
How have you felt in the past month? (please tick as many that apply to you)
Neither well nor bad
Not feeling pleasure
Having little interest
If possible, can you tell us more about what has been going on for you?
Are you currently, or have you recently been, receiving treatment for these difficulties?
If yes, please tell us what treatment or support you are having, or have had, including if it has been helpful or not
Are you currently taking any medication?
If yes, please tell us the names and doses (if known)
Is there anything else you would like us to know?