Birth reflections form

Birth reflections service

Please complete all fields marked with an astrix (*)

Birth Reflections provides people who have given birth at Stoke Mandeville Hospital with the opportunity to talk about their birth experience and explore their feelings and thoughts with a midwife.

We suggest waiting a minimum of six weeks after the delivery to give yourself time to process what happened - we can offer you an appointment up to a year after the birth, or more if you are currently pregnant or are planning to become pregnant again

Once a self-referral form has been submitted, you will receive an email confirming receipt, and advising on the estimated wait time.
You will be contacted by the Birth Reflections Midwife to arrange a date/time/location that suits you by email/telephone – if we do not receive a response within 21 days we will presume you no longer require an appointment.
Your Birth Reflection appointment can only be re-arranged once. Due to a limited number of appointments available per week, you will be required to re-submit a self-referral form should you cancel your re-arranged appointment.

Your name

Your date of birth

Your baby's date of birth

Contact number

Email address

Do you have any communication requirements:

I would like an interpreter - please include details below. I have a learning disability I am deaf / have a hearing impairment I am blind / have a sight impairment Other - please include details below. I don’t have any specific communication requirements

Please give relevant details:

What would you like to discuss at your birth reflections appointment?

Please note: this service is not for formal complaints. If you have any concerns with regards to the care you’ve received, please contact bht.pals@nhs.net who will make sure your concerns are appropriately addressed.

Thank you for requesting a birth reflections appointment. One of our midwives will contact you within the next 4 weeks. If you don’t hear from us, please call 01296 255760.