Referral form

Hertfordshire Postnatal Illness Support
Registered charity 1107512

(Name & address here)
(Date)

Dear Doctor,

Since having my baby I have had the following symptoms :- (please tick)

[ ] I feel as if I am a "bad" mum

[ ] I had a traumatic birth and I feel like I haven't got over it

[ ] I have horrible and distressing thoughts about myself and my baby

[ ] I sometimes imagine myself harming my baby

[ ] My mind is continually racing, particularly when I try to sleep

[ ] I am unable to eat or sleep properly

[ ]I am worried that I might become too unwell to look after my baby

[ ] I had depression before I became pregnant

[ ] I feel "not right in myself"

[ ] I feel like I'm going crazy

[ ] I don't feel in control of myself

[ ] My emotions scare me

[ ] I am hiding how I really feel and pretending everything is OK

[ ] I have been frightened by the intensity of my symptoms and would like to ask for help. Please tell me what I can do to make this better and what services there are to help me.

Thank you.

(Sign here)