Form for pregnancy and hypnobirthing referrals

Please complete the details on the form below. This will form the basis of therapy, so accuracy is important. You may feel some of the questions don’t appear particularly relevant to your situation. However, it is essential for me to gain a basic understanding of your life circumstances to aid effective therapy.

Name

Address

Telephone

Preferred Contact Method

Date of birth

Any children? (Please list ages)

Estimated due date

Midwife name

Midwife surgery

Next of kin name

Next of kin phone

Other professional support

Details of any medication

What kind of birth are you planning for?

Are there any other issues you feel may be relevant?

Seeking your consent to treatment is a legal and insurance requirement

I wish to receive treatment from S Mustard based upon the presenting issues agreed and any additional issues that arise from subsequent sessions. I also confirm that I have read and understand the terms of treatment within the Practice Information document.

I agree to the above.

GP/Health professional consent form

I give permission for S Mustard to contact my GP/care co-ordinator, if it is deemed appropriate during the course of my treatment. I understand that the reasons would be fully discussed with me prior to contact being made. I understand that in this event, only information relevant to my treatment would be discussed.

I agree to the above.

Pregnancy & Hypnobirthing Service registration form

Seeking your consent to treatment is a legal and insurance requirement

GP/Health professional consent form