Professional Form Perinatal Mental Health Referral (City and Hackney) First name Surname NHS Number: if you know it DOB Format: d.m.y Address Address Address 2 City/Town ZIP/Postal Code Permanent address? Yes No Mobile Telephone Preferred Language Interpreter required? Yes No Ethnicity Nationality Preferred type of appointment Face to Face Virtual GP Name GP Address GP Postcode GP Telephone Referrer name Referrer Job Title Referrer address and telephone number Referrer Postcode Referrer Email A copy of your submission will be sent to the email provided. Reason for referral (brief summary of problems) Is patient aware of referral? (including attitude to referral) Yes No Psychiatric History ( if yes & include further relevant information i.e. diagnosis, past psychiatric admissions, history of relapse) Depression Severe Depression Postnatal Depression Anxiety Eating Disorder Bipolar affective Schizophrenia Schizo Affective illness Postnatal Psychosis Alcohol/Substance Misuse Past Psychiatric Admissions Personality Disorder OCD Other Other (please state) Details Psychiatric Medication (include name, dose, date of last review and compliance) (If yes) Yes No Stopped (include date psychiatric medication stopped) Details Suicide and/or Self-harm (if yes) Past Present Details PHQ-9 scores GAD-7 scores Emotional Wellbeing in Past Month (if yes) Satisfactory/Good Feeling Hopeless Feeling Down Feeling Depressed Having Little Interest Not Feeling Pleasure Medical history (If yes, include further relevant information including current medication) Details Details Current Mental Health Treatment Provided by (if yes) CMHT Care Co-ordinator Psychiatrist Psychologist GP Specialist Addiction/Alcohol Service Non-NHS Family Mental Health History (if yes) Partner Father Mother Sibling Client's Child Sister Aunt If female relative, was this in perinatal period? Yes No Medical history (If yes, include further relevant information including current medication) Where is she receiving antenatal care: (Does she attend, engage with maternity services) Obstetrician Named midwife EDD Gravida Parity Attitude to the pregnancy/baby Children: (Include full names & DOB's) Please provide details about children including first name, surname, sex, date of birth, where they are living and who with for each child. Any past or current concerns including child protection/formal court proceedings (if yes) Yes No Child protection/formal court proceedings If there are child protection/formal court proceedings ongoing, please give details including named workers. Current social circumstances Social Support (or lack of) Relationship with Partner Relationship with Family Employment Immigration/Seeking Asylum Housing/Homelessness Financial/Debts Current social circumstances: (detail of problems) Risk assessment Dangerous/Risk To Others Risk Of Self-harm Self-neglect Vulnerability Domestic Violence Child Protection/Safeguarding Concerns Financial/Debts Risk assessment (further detail) Please include at least two of the following assessments (for Mental Health Services only) if yes Risk Checklist/Assessment Initial Assessment or Full Needs Assessment CPA Document Recent Discharge Summary Recent Psychiatrist Review Letter Are you currently pregnant or recently given birth? Yes No Date of Next Appointment Attach Documents Please upload if relevant any of the following: Completed outcome measures e.g. PHQ-9 and GAD-7, Most recent clinic letter, Most recent mental health assessmentMaximum 5 files.64 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.