Self Referral Form Perinatal Mental Health Referral (Tower Hamlets) First name Surname NHS Number: if you know it DOB Format: d.m.y Age Address Address Address 2 City/Town ZIP/Postal Code Permanent address? Yes No Mobile Telephone Preferred Language Interpreter required? Yes No Ethnicity Nationality Religion Marital status Email address GP Name GP Address GP Postcode GP Telephone Reason for referral (brief summary of problems) Feelings: can you describe how you are feeling? Please tick ones relevant to you Hopelessness Down Fear Isolated Unreal Panicky Suicidal Lonely Trapped Intrusive Thoughts Have you had previous history of: (if yes include further relevant information i.e. diagnosis, past psychiatric admissions, history of relapse) Depression Severe Depression Postnatal Depression Anxiety Bipolar affective Schizophrenia Schizo Affective illness Psychosis in Postnatal Period Alcohol/Substance Misuse Past Psychiatric Admissions Obsessive Compulsive Disorder Details 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) Current Social Circumstances: (detail problems in the areas listed) Social Support (or lack of) Relationship with Partner Relationship with Family Employment Immigration/Seeking Asylum Housing/Homelessness Financial/Debts Details If you get appointment would you prefer it Face to Face Virtual Details Are you currently pregnant or recently given birth? Yes No Estimated Delivery Date CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.