Self-Referral Form

Maple Service

We are a specialist service offering therapy and support if you have experienced:
 the loss of a pregnancy or a baby (up to 18 months old),
 a traumatic birth
 an ongoing fear of childbirth
and you are feeling very emotionally distressed or experiencing mental health problems in relation to this.

We work with women/birthing people and fathers/partners.

To be able to receive our support you need to live in Barnet, Camden, Enfield, Haringey or Islington.

Section 1 - Your Details

Please underline borough of residence: Barnet Camden Enfield Haringey Islington

First Name
Surname
Address

Contact Telephone Can we text this number? Yes No

Can we leave a voicemail Yes No
Email Address
Date of Birth & Age
Ethnic Origin
Section 2 – GP details and Physical Health
GP Name
GP Address

Do you have any physical health problems you would like us to know about?

Section 3 – Pregnancy and Postnatal Information

Have you experienced the loss of a pregnancy or a baby (up to 18 Yes No
months old)? (If yes, please go to section 4)

Are you or your partner pregnant, or a parent of a child below the Yes No
age of 18 months?
If you or your partner are pregnant, what is your expected delivery
date?
If you or your partner are pregnant, where are you receiving
antenatal care? (If known)
If you have children, please provide their name(s) and date(s) of
birth:

Interim Chair: Peter Molyneux

Better Mental Health. Better Lives. Better Communities. Chief Executive: Jinjer Kandola MBE
Section 4 – Your experiences and what you would like help with
Can you tell us a bit about what has happened, and what made you want to contact us?

Can you tell us about how it has affected you? (for example, feeling very anxious, more sad or angry than usual,
having flashbacks and or/nightmares, feeling hopeless)

Are you currently, or have you recently received support Yes No

or treatment for these difficulties?
If yes, can you tell us about the support or treatment you are having, or have had, including if it has been helpful or
not?

Are you currently taking any medication? Yes No

If yes, please tell us the names and doses (if known)

Is there anything else you would like us to know?

Please complete electronically and email: NCL.perinatal@candi.nhs.uk

This is not an emergency service

For emergency help call 999 or direct people to mental health liaison at their local A&E department.
For urgent help contact your local crisis line: Barnet, Enfield & Haringey 0800 151 0023
Camden & Islington 0800 917 3333

Interim Chair: Peter Molyneux

Better Mental Health. Better Lives. Better Communities. Chief Executive: Jinjer Kandola MBE