Before making this referral

Please ensure you have read the information about where the service is available and eligibility criteria on the maternity trauma and loss care page. You can also use the contact details there if you need any further advice or support with referring yourself to the service.

Please be aware that the Maternity Trauma and Loss Care Service is not an urgent or 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. 

 For residents in Ealing, Hounslow or Hammersmith and Fulham, this is:
West London NHS Trust Single Point of Access
Phone 0800 328 4444

​​​​​​​For residents in Brent, Harrow, Hillingdon, Kensington and Chelsea or Westminster, this is:
Central and North West London NHS Foundation Trust Single Point of Access
Phone 0800 0234 650

Date completed

Section 1 - Your details

Date of birth Required
Address Required
Can we contact you by email? Required
Can we leave voice messages on this number? Required
Can we send text messages to this number? Required

Section 2 – GP information

GP surgery address Required

Section 3 – Pregnancy and postnatal information

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 date of birth?
If you are pregnant, where are you receiving antenatal care? (if known):

Section 4 – 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 Required
How have you felt in the past month? (please tick as many that apply to you) Required
Are you currently, or have you recently been, receiving treatment for these difficulties? Required
Are you currently taking any medication? Required
How did you hear about us? Required