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: dhc.referrals.perinatalcommunity@nhs.net

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.

Emergency: if the referral is an emergency the client will be contacted within four hours Non-urgent: if the referral is non-urgent the client will be contacted within 28 days.

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 *

I confirm

Referrer name *

Profession *

Where based (please supply full address) *

Mobile number/landline *

Email address *

Has the client been made aware of this referral?

Yes No

Client name (including title) *

NHS number *

Date of birth *

Current address *

Postcode *

Type *

Antenatal Postnatal

Daytime contact number

Evening contact number

Mobile number *

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 *

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

Ethnicity *

Nationality *

Preferred language

Religion

Occupation

Employment status

Marital status

Is an interpreter required? *

Yes No

Next of kin *

Next of kin contact number *

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 *

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 *

Include any concerns regarding mother infant bond/attachment *

Diagnosis if known:

Current medication

Client's physical state *

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) *

Can client be visited by a lone worker?

Yes No

Other services currently under

Drug, alcohol, forensic history

Drug

Alcohol

Forensic

We direct you to our privacy notice for further information on how we share your information and refer on to other services we feel will best meet your current needs.