Perinatal mental health referral form

The team welcomes referrals from health professionals and social workers, for women and birthing people registered with a GP and living in Dorset, with a significant mental illness during the perinatal period.
We request that referrers take time to familiarise themselves with the Dorset Perinatal Pathway and referral criteria, so as to ensure women and birthing people are receiving the most appropriate care, in a timely manner.  The Perinatal Pathways screening tool is recommended to be used as a guide to determine what level of support a birthing person may need based off their symptoms/ answers– please consider this in-line with clinical presentation and discussion with the individual and their family.

Referral enquiry email:

Please complete all sections. Failure to complete may result in a delay in your referral being processed.

All referrals are screened on a daily basis Monday-Friday and a decision is made based on the information provided as to the urgency of our response.

The assessors will decide which service is required during the screening process. 

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.


Please contact the perinatal team to discuss any emergency referral on 01202 584329 from 9am-4.30pm Mon-Fri prior to submitting this online form

Please tick to confirm you have contacted the perinatal team and that they are aware of the emergency referral *
Has the client been made aware of this referral?
Type *

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.

Failure to provide a correct and up to date email address may delay your referral being processed through our clinical system.

Is an interpreter required? *
Can client be visited by a lone worker?
Drug, alcohol, forensic history