Pregnancy 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 are booked to give birth at, or are receiving your maternity care from Calderdale and Huddersfield NHS Foundation Trust.
Please contact the Maternity Assessment Centre (MAC) on 01422 224 392 if you have any pregnancy concerns. For example:
- Vaginal bleeding
- Fluid loss
- Changes to your baby’s movements.
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.