Please indicate whether you feel that this referral warrants immediate attention (classified as emergency) or whether it is non-urgent by marking the appropriate box.
Is this referral classified as an emergency or routine?
* Required** None Emergency Routine
Emergency: if the referral is an emergency the client will be contacted within four hours. Please tick to confirm you have contacted the perinatal team and that they are aware of the emergency referral
I confirm
Routine: if the referral is routine the client will be contacted within 28 days.
Referrer name
* Required
Profession
* Required
Where based (please supply full address)
* Required
Mobile number/landline
* Required
Email address
* Required
Has the client been made aware of this referral?
Yes
No
Client name (including title)
* Required
NHS number
* Required
Date of birth
* Required
Current address
* Required
Type
* Required
Antenatal
Postnatal
Daytime contact number
Evening contact number
Mobile number
* Required
We are moving to digital communication for all our clinical letters. Please ask the patient for their email address and inform them that, by providing this, they are consenting and agreeing to all clinical documentation being sent electronically from the Perinatal Mental Health Service to their email address. Please ensure the correct email address is submitted. If patient preference is to opt out of this, please contact the service directly where we can update individual's preferences.
Email address
* Required
Failure to provide a correct and up to date email address may delay your referral being processed through our clinical system.
Nationality
* Required
Ethnicity
* RequiredWhite – British White – Irish White – Any other background Mixed – White & Black Caribbean Mixed – White & Black African Mixed – White & Asian Mixed – Any other mixed background Asian or Asian British – Indian Asian or Asian British – Pakistani Asian or Asian British – Bangladeshi Asian or Asian British – Any other background Black or Black British – Caribbean Black or Black British – African Black or Black British – Any other background Other Ethnic Groups – Chinese White – Northern Irish White – Other/Unspecified White – English White – Scottish White – Welsh White – Cornish White – Cypriot (part not stated) White – Greek White – Greek Cypriot White – Turkish White – Turkish Cypriot White – Italian White – Irish Traveller White – Traveller White – Gypsy/Romany White – Kosovar White – Polish White – All Republics of former USSR White – Albanian White – Bosnian White – Croatian White – Serbian White – Other Republics of former Yugoslavia White – Mixed White White – Other European Mixed – Black and Asian Mixed – Black and Chinese Mixed – Black and White Mixed – Chinese and White Mixed – Asian and Chinese Mixed – Other/Unspecified Asian or Asian British – Mixed Asian Asian or Asian British – Punjabi Asian or Asian British – Kashmiri Asian or Asian British – East African Asian Asian or Asian British – Sri Lanka Asian or Asian British – Tamil Asian or Asian British – Sinhalese Asian or Asian British – British Asian or Asian British – Caribbean Asian Asian or Asian British – Other/Unspecified Black or Black British – Somali Black or Black British – Mixed Black or Black British – Nigerian Black or Black British – British Black or Black British – Other/Unspecified Other Ethnic Groups – Vietnamese Other Ethnic Groups – Japanese Other Ethnic Groups – Filipino Other Ethnic Groups – Malaysian Any Other Group Other Ethnic Groups – Arab Other Ethnic Groups – North African Other Ethnic Groups – Other Middle East Other Ethnic Groups – Arab Other Ethnic Groups – North African Other Ethnic Groups – Other Middle East Other Ethnic Groups – Israeli Other Ethnic Groups – Iranian Other Ethnic Groups – Kurdish Other Ethnic Groups – Moroccan Other Ethnic Groups – Latin American Other Ethnic Groups – South/Central American Other Ethnic Groups – Maur/SEyc/Mald/StHelen
Preferred language
Religion
Occupation
Employment status
Marital status
Is an interpreter required?
* Required
Yes
No
Next of kin
* Required
Next of kin contact number
* Required
Expected date of delivery
Baby's DOB
Baby's full name (if applicable)
Baby's physical state: (if applicable)
Dependent(s) and date(s) of birth: (If applicable)
Baby's father/co-parent name (if applicable)
GP name
Surgery
* Required
Phone number
Email address
Full address
Midwife name
Mobile number
Address where based
Email address
Client health visitor name
Mobile number
Address where based
Email address
Client's Mental Health Worker Name
Mobile number
Address where based
Email address
Family Social Worker Name
Contact number
Address where based
Reason for referral and current mental state
* Required
Include any concerns regarding mother infant bond/attachment
* Required
Diagnosis if known:
Current medication
Client's physical state
* Required
Past psychiatric history (including diagnosis, section/informal, interventions tried, medication-dose/length, with what response? Is there a family history of severe mental illness?)
Identified Risks (please consider the following e.g. violence, self-harm, suicide)
* Required
Can client be visited by a lone worker?
* Required
Yes
No
Other services currently under
Drug, alcohol, forensic history
Drug
Alcohol
Forensic
