PERINATAL MENTAL HEALTH SERVICE
REFERRAL FORM
INFORMATION FOR REFERRERS
The perinatal mental health service offers specialised treatment to women experiencing significant mental health difficulties during pregnancy or if they have a child below one year of age.
We are a tertiary service and accept patients where intervention in primary care has been unsuccessful or where the severity or risks of the illness require specialised input.
A Referral should be made early in the pregnancy and at the latest, by the end of the second trimester in the following circumstances:
Previous history of puerperal psychosis
Diagnosis of bipolar affective disorder
Diagnosis of schizophrenia
Previous severe depressive episode/post natal depression-requiring treatment in hospital/secondary care.
Other appropriate referrals include:
Current puerperal psychosis-if suspected, urgent referral required
Moderate or severe antenatal/postnatal depression or anxiety disorders
If the patient is under the care of mental health services, the referral must be made by the care-coordinator or consultant.
For routine referrals with no associated risks, the following should be considered within primary care before making a referral:
Increased support from health visitor/maternity support midwife
Referral to children’s centre/intensive family support service
Primary care counselling
Trial of medication where appropriate
We aim to see routine referrals within 14 days and urgent referrals within 72 hours
In cases of suspected puerperal psychosis we aim to see the patient the same day.
We cannot accept urgent referrals or undertake assessments outside of office hours. (Mon-Fri, 9-5) We may be able to facilitate an admission if a psychiatric assessment has been undertaken.
In urgent cases- for example, suspected puerperal psychosis or risk of suicide, if we cannot facilitate an urgent assessment, a referral to the crisis resolution home treatment team will be necessary.
Urgent referrals must be discussed with a member of the duty team.
We can only accept referrals where the patient consents to assessment. If a patient does not consent, their GP will need to assess whether a Mental Health Act assessment is appropriate.
We are happy to discuss potential referrals or be contacted for advice
To speak to a member of the duty team contact 0113 8555505 or 0113 855509
Please FAX completed referral form to 0113 8555506
PERINATAL MENTAL HEALTH SERVICE
REFERRAL FORM
DATE OF REFERRAL …………………PATIENT CONSENT OBTAINED [ ]
REASON FOR REFERRAL
Assessment and treatment/advice[ ]
Admission to mother and baby unit[ ]
Preconception counselling[ ]
NATURE OF REFERRAL
Routine [ ]Urgent [ ]
If urgent, please give reasons below and contact member of the duty team to discuss:
………………………………………………………………………………………….
………………………………………………………………………………………….
………………………………………………………………………………………….
If routine, please confirm the following:
Discussed with GP[ ]
Primary care interventions undertaken/response
……………………………………………………………………………………….
……………………………………………………………………………………….
PATIENT DETAILS
Name…………………………………………………………………………………
D.O.B………….
Address………………………………………………………Postcode…………….
NHS number……………………………………..
Contact Numbers……………………………………………………………………..
Next of kin……………………………………………………………………………
Ethnicity……………………………Preferred language…………………………….
ALL FIELDS MUST BE COMPLETED OR DISCUSSED WITH DUTY TEAM BEFORE REFERRAL CAN BE ACCEPTED
CHILDREN’S DETAILS
Full name(s)…………………………………………………………………………….
DOB(s)…………………………………………………………………………………
Address ………………………………………………………………………………..
(if differs from mother’s)
EDD if pregnant………………………………
INVOLVED PROFESSIONALS
Referrer………………………………Profession……….………………………….
Address (inc postcode)………………………………………………………………
Contact no………………………………………
Email address……………………………………..
GP…………………………………….Address………………………………………
Contact no.……………………………Aware of referral?......
Midwife………………………………Address………………………………………
Contact number………………………Aware of referral?......
Health visitor………………………….Address…………………………………
Contact no…………………………… Aware of referral?......
Children’s social worker…………………………………Address ……………………………….
Contact no……………………………Aware of referral?......
CURRENT MENTAL HEALTH DIFFICULTIES
(Mood, anxiety, obsessional symptoms, psychotic symptoms, sleep, appetite etc)
SUICIDAL IDEATION/PLANS
RELATIONSHIP WITH INFANT
Breastfeeding Y/N
CHILD PROTECTION CONCERNS (if identified, referrer to discuss with CP supervisor/refer to children’s social care)
CURRENT MEDICATION(including start dates for psychotropic medication)
PAST PSYCHIATRIC HISTORY
DRUG/ALCOHOL MISUSE
ADDITIONAL INFORMATION
ADDITIONAL INFORMATION REQUIRED FOR REFERRAL TO
MOTHER AND BABY IN-PATIENT UNIT
Patient consenting to admission: Yes/No
Detained under Mental Health Act? Yes/No
If detained: date section expires:………………..
If detained, is patient agreeable to transfer to Mother and Baby Unit? Yes/No
Name of infant’s father……………………………..
Father’s contact details………………………………………
If fatherholds parental responsibility, are they agreeable to admission? Yes/No (If no, admission can not proceed)
Are children’s social care involved?
Name of infant’s social worker………………………………………………………..
Address…………………………………………………………………………..
Contact no……………………………………
Please confirm they are in agreement with admission? [ ]
Is child subject to a protection plan? Y/N
Is the child subject to a care order? Y/N
(Please fax copies of any child protection reports/assessments/meeting minutes)
In the event the infant is unable to remain with the mother (due to her current mental health difficulties), who will provide care for the infant? In the absence of an appropriate carer, this would need to be the local authority.
Name…………………………………………………………………………………
Address………………………………………………………………………………
Contact no.……………………………………………………………………………..
CARE COORDINATOR
NAME……………………………………..BASE ADDRESS…………………………………….
CONTACT NO………………………………………………….
(Care coordinator will be required to attend regular CPAs)
CURRENT MENTAL STATE (must include presence/absence of symptoms involving infant)
LEVEL OF INSIGHT: Does patient accept the need for treatment
CURRENT RISK TO SELF
RISK TO OTHERS-any history of, or current verbal/physical aggression? Would patient pose any risk to other mothers/infants?
CURRENT ABILITY TO CARE FOR INFANT, INCLUDING RISKS
WILL PATIENT ACCEPT GUIDANCE/INTERVENTION RE CARE OF HER BABY?
IF PATIENT KNOWN TO PSYCHIATRIC SERVICES, THE FOLLOWING MUST BE FORWARDED
Current CPA documentation
Relevant correspondence ( d/c summary, clinic letters)
Up to date risk assessment