Post-Natal Self-Referral Form
You are about to complete a self-referral to the Women's Health Physiotherapy Team. This is part of the Perinatal Pelvic Health Service (PPHS). Women and birthing people can self-refer at any point during pregnancy, and up to 12 months after birth.
We only accept referrals for the following problems:
- Leaking of urine (wee) and/or stool (poo)
- Pelvic organ prolapse (lump or buldge in the vagina)
- Pain with sexual intercourse
- Birth injuries to the area between the vagina and anus
Please complete all sections of this referral form to the best of your ability. This will ensure it is triaged correctly by our team.
Please only complete this form if you have received your maternity care from Calderdale and Huddersfield NHS Foundation Trust.
The form takes 15-20 minutes to complete, so please ensure you have time to complete the form fully in one sitting.
Please ask your GP to refer you to your local Perinatal Pelvic Health service.