Birth Reflections self-referral form

Section One

Did you have your baby at East Sussex Healthcare NHS Trust? (required)

Yes

No, but I would like to talk about my antenatal and/or postnatal care at East Sussex Healthcare NHS Trust

No, I had my baby in another hospital and wish to talk about the birth.

If you had your baby in another Trust, please contact them or visit their website to find out what services they offer.

For University Hospitals Sussex NHS Foundation Trust, see: Birth stories - University Hospitals Sussex NHS Foundation Trust

For Maidstone and Tunbridge Wells NHS Trust, contact the midwifery liaison office on 01892 638158 or 01892 633488 - Monday to Friday 8.30 am to 4pm.

Are you filling in this form for someone else and with their permission? (required)

Yes

No

If you are filling in this form for someone else, how do you know this person? (eg family member, friend, health professional) (required)

Did you have your baby at least 6 weeks ago? (required)

Yes

No

If your baby is less than six weeks old, please speak to your midwife or health visitor. If, once your baby turns six weeks old, you feel this service would be of benefit to you, please self-refer at that time.

Section 2

About you and your baby (babies)...

Full name (required)

First

Last

Your date of birth (required)

Your hospital number or NHS number (if known)

What is the best number to call you on? (required)

What is your email address?

Your baby's date of birth (required)

Are you pregnant? (required)

Yes

No

Estimated Date of Birth/Delivery (or EDD) (required)

Section 3

About your experiene

Please tell us what you would like to talk about. This will help us prepare for your appointment (required)

Section 5

Is there anything else you would like to tell us?