Perinatal Pelvic Health Service antenatal self-assessment / referral form

This antenatal form should be used to make a referral to the Perinatal Pelvic Health Physiotherapy Service (PPHS).   

Please complete all sections of this antenatal referral form to the best of your ability. This will ensure we can best align your care tailored to your pelvic health concern.

After completing your form, you will either be sent a link with information and resources available, or an invitation to a workshop which can be watched at home (pre-recorded version), or attended online or in person, depending on your local area provision and availability. In some instances, you will be offered a face-to-face appointment with the clinical specialist team.

If your symptoms change at any point, or you do not feel you have received the care you need, you can re-refer at any time up to 18 months postnatal by filling out the postnatal self-referral form or you can speak to your midwife, GP or health visitor.