Waltham Abbey Midwives Self Referral Form

WALTHAM ABBEY MIDWIVES SELF-REFERRAL

Note: Questions marked by * are mandatory

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  Yes No Both
DRUG/ALCOHOL MISUSE
MENTAL HEALTH PROBLEMS
LEARNING DISABILITY
PREVIOUS/CURRENT DOMESTIC VIOLENCE
CHILDREN HAVE/HAD CHILD PROTECTION/CHILD IN NEED PLAN?
PREVIOUS OR CURRENT CONTACT WITH SOCIAL SERVICES?
IS THERE ANY HISTORY OF FEMALE GENITAL MUTILATION IN THE FAMILY



Inpatient comment:

Everyone offered words of such reassurance and kindness. I felt so cared for and the communication with me at all times was fantastic.