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Birth reflections self-referral form

Sometimes, after giving birth, you’re left with questions, feelings or moments you’d like the chance to talk through. Our Birth Reflections service offers a safe, supportive space to revisit your experience with a specialist midwife - whether your baby was born weeks, months or even years ago.

If you feel ready to reflect on your pregnancy, labour or postnatal care, you can now self-refer directly through our online form. The service is open to anyone who gave birth at York or Scarborough Hospital and aims to help families better understand their experience, ask unanswered questions and access further support if needed.

About You

First name*

Last name*

Date of birth*

Address including postcode*

NHS Number

Contact telephone number (we might call or text)*

Do we have permission to leave a message>*

Email address*


Referral question

How did you find out about this service? (eg midwife/doctor/health visitor/friend etc)

When did you find out about this service? (eg antenatally/postnatally/during hospital stay etc)

Where did you receive the majority of your antenatal care?

What was the date of birth of your baby?*

Which hospital did you deliver your baby/babies? ( if homebirth then please state which hospital you were booked at)*

Are you currently pregnant?

If yes, when is your due date?

In your own words please tell us what you like to discuss during your birth reflections appointment

Email 2*:

* required fields

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The resident doctors' strike that was due to start today, Monday 15 June, has now been called off. Please continue to attend any appointments as planned and access NHS services as normal if you need them.