Neonatal reflections self-referral form

Having a baby on the neonatal intensive care unit is a stressful time. It can take some weeks or months to process what actually happened when you were there. This can sometimes lead to questions that you felt were left unanswered or issues that you feel you need to talk about.

This can help you better understand what happened, help you clarify decisions that were made around your child’s treatment and help you address any unanswered queries that you may have.

This Neonatal Reflections Service is available for anyone who had a baby or babies on the Neonatal Unit at The James Cook University Hospital, regardless of where you originally booked to have your baby delivered.

We will identify a convenient time for you, and you can bring your partner or other support person with you when we meet if you wish. Whilst face to face meetings are desirable, on-line meetings may be available for those families who were transferred from outlying areas in the region or beyond.

We have not put any time limit on how long ago your neonatal experience was and would prefer that if you had anything that you did wish to talk about, you made contact with us.

Once the following form has been submitted, we aim to answer your referral within 14 days. If this is not the case, please email us directly on: [email protected]

Neonatal reflections self-referral form

South Tees Hospitals neonatal reflections online self-referral form.

Full name of referrer (parent of the child):(Required)

Baby’s name (or names):(Required)

Date of birth of the baby:(Required)

Address(Required)

Street Address Address Line 2 ZIP / Postal Code

Telephone number you are happy for us to contact you via:(Required)

Baby's NHS number (if known):

Can you give us an idea of the most important thing that you would like to address in your baby’s neonatal journey?(Required)

I have some questions about my child’s neonatal journey and would like to talk it through with the neonatal team.

I am worried about my emotions following my neonatal journey and I would like information on where I can seek support

I am unhappy with the standard of our care on the neonatal unit.

Other – please explain below

Please tick as many as required

In your own words please tell us a little about your neonatal experience in the box below and what you would hope to gain from a neonatal reflection’s discussion:

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