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Enquiry Form

Let’s See If I’m the Right Fit for You

Completing this form is the first step in exploring whether my service is the right fit for your needs. I’ll review your enquiry and get back to you as soon as possible.

Before we continue with the enquiry from, I want to ensure you’re feeling safe and supported. Are you currently feeling overwhelmed by intense anxiety or experiencing distressing thoughts, such as self-harm or suicidal feelings?

yes no

If you do not feel safe or feel overwhelmed with negative or anxious feelings, please consider calling an NHS crisis line, which is available in all NHS areas. You can also call Samaritans on 116 123 or call NHS 111. In an emergency, please call 999 or visit your local A&E department.

📞 Call Samaritans 📞 Call NHS 111 🚨 Call 999

Thank You

Please complete all the sections in this form to the best of your ability, as it will help me to determine the best course of action.

Support Required

Preconception Advice Antenatal Appointments

First Name

Last Name

Phone

I am currently well but have suffered in the past:

Anxiety states OCD Mood swings Depression Bipolar disorder Schizophrenia Substance misuse/ addiction

Any other problems, please state:

Thank You

Please let me know about any symptoms or concerns you’re experiencing with preconception so I can better understand how to help you.

Select all that apply:

Emotional Wellbeing

Anxiety or excessive worry about pregnancy Depression or low mood Panic attacks Difficulty managing stress Mood swings or emotional instability Obsessive thoughts or compulsive behaviours Feelings of overwhelm about starting a family Past experiences of trauma impacting your mental health Fear of childbirth (Tokophobia) Relationship difficulties related to family planning

Medication and Treatment Concerns

Uncertainty about current medications and pregnancy safety Concerns about stopping or adjusting psychiatric medication Need for alternative treatment options Previous negative experiences with psychiatric medications Interest in exploring non-medication strategies to manage mental health

Lifestyle and Wellbeing

Trouble sleeping or insomnia Poor appetite or disordered eating Chronic fatigue or low energy levels Frequent headaches or physical tension linked to stress Concerns about exercise routines and their impact on pregnancy Managing work-related stress during family planning

Family History and Genetic Concerns

Family history of mental health conditions Concerns about passing on genetic mental health risks Interest in genetic testing for mental wellbeing insights

Hormonal and Biological Factors

Polycystic ovary syndrome (PCOS) or hormonal imbalances Thyroid issues affecting mental health History of postpartum depression or anxiety History of menstrual cycle-related mood issues (e.g., PMDD)

Social and Environmental Concerns

Feeling unsupported by family or partner Financial stress impacting family planning Concerns about balancing motherhood and career Previous negative experiences with healthcare providers

Other Concerns

Uncertainty about when to start trying for a baby Concerns about how pregnancy might impact your mental wellbeing Fear of losing personal identity during motherhood Previous miscarriages or fertility challenges impacting mental health

Thank You

Pregnancy can bring a range of emotions and experiences, and I'm here to support you. Please let me know about any symptoms or concerns you may have so I can provide the best care for you.

Select all that apply:

Emotional Wellbeing

Anxiety about pregnancy or childbirth Depression or persistent low mood Panic attacks or feelings of intense fear Intrusive thoughts or obsessive behaviours Difficulty bonding with your unborn baby Mood swings or emotional instability Feelings of overwhelm or being unable to cope Past trauma or distress triggered by pregnancy Fear of childbirth (Tokophobia) Relationship difficulties during pregnancy

Medication and Treatment Concerns

Uncertainty about continuing psychiatric medication during pregnancy Concerns about the safety of current medications Fear of stopping or adjusting psychiatric medication Side effects from medications affecting your wellbeing Interest in non-medication approaches to manage mental health Need for guidance on pregnancy-safe treatments

Physical and Lifestyle Factors

Insomnia or disrupted sleep patterns Persistent fatigue or low energy Poor appetite or disordered eating Headaches, migraines, or tension linked to stress Struggles with morning sickness impacting mental wellbeing Difficulty maintaining a healthy lifestyle during pregnancy

Social and Environmental Factors

Feeling unsupported by your partner, family, or friends Relationship stress or conflict during pregnancy Financial concerns related to preparing for your baby Workplace stress impacting your mental health Difficulty accessing support or feeling isolated

Pregnancy-Specific Mental Health Concerns

Worry about the baby’s health and development Fear of pregnancy complications Concerns about labour and delivery Previous traumatic birth experiences Managing grief from previous pregnancy loss or miscarriage Concerns about your ability to bond with your baby

Early Parenting Concerns

Fear of developing postnatal depression or anxiety Concerns about coping with the demands of early parenthood Worries about how your mental health may impact your baby’s wellbeing

Other Concerns

Feeling emotionally disconnected from your pregnancy Concerns about balancing pregnancy with existing responsibilities Fear of losing your identity as you become a parent Previous negative experiences with healthcare providers

Any other matters

Get in Touch

Contact Details

1a Milton Road, London, N6 5QD, UK

+1 800 603 6035 or +1 800 603 6036

info@yourmentalwellbeing.com

Monday - Saturday: 8AM - 5PM , Sunday: 10AM - 2PM

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Let’s See If I’m the Right Fit for You

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