Lotus self-referral form

Your information

Note: Questions marked by * are mandatory

The Lotus Maternal Therapeutic Outreach Team work closely with other services to offer support to women and birthing people: Who experience a fear of childbirth (Tokophobia), have experienced a birth trauma, have experienced a perinatal loss during pregnancy, birth or up to 1 year following birth, have been separated from your baby or child by Children's services involvement up to 1 year following birth. After completing this form a member of our staff will be in contact to further understand your needs and hopes for yourself from the service. If you need immediate help, or in the event of any emergency, please dial 999. Alternatively, for support with your mental health please call the NHS mental health crisis service on 111, selecting the mental health option.

*This is a mandatory field. First name

*This is a mandatory field. Last name

*This is a mandatory field. Date of birth

*This is a mandatory field. Telephone number

*This is a mandatory field. Is it ok to leave a voice message?

Yes
No

*This is a mandatory field. Your address

Email address

Would you be open to a Microsoft Teams video call, as an alternative to a telephone call to discuss your experience?

Yes
No

*This is a mandatory field. GP Surgery (please indicate if none)

If you require an interpreter, please specify the language