Birth Reflections Self Referral Form

Thank you for your interest in the Birth Reflections Service. By registering it is understood that you would like to talk about aspects of your pregnancy, the birth of your baby or your immediate postnatal care. By completing the below form, you are requesting a Birth Reflections appointment.

It is important to note that this service is only available for women or birthing people, who have birthed their baby/s with us at Salisbury District Hospital (SDH) or had a homebirth facilitated by SDH. You can make a referral up to 10 years after the birth of your baby. However, we recommend that you wait until at least 6 weeks following the birth before registering. Whilst you can still make a referral to the Birth Reflection Service at any time, we are unable to offer appointments before six weeks following the birth if your baby/s.

Full Name [Required]

Date of Birth

Address [Required]

City

County [Required]

Post Code [Required]

Contact Number [Required]

NHS number

Date of your baby’s birth [Required]

Please provide a brief description as to what aspects of your care you would like to discuss:

Consent for storing submitted data [Required]

Yes, I give permission to store and process my data

reCAPTCHA [Required]

Our staff at Salisbury District Hospital have long been well regarded for the quality of care and treatment they provide for our patients and for their innovation, commitment and professionalism. This has been recognised in a wide range of achievements and it is reflected in our award of NHS Foundation Trust status. This is afforded to hospitals that provide the highest standards of care.