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- Community referral form for professionals

Community referral form for professionals

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For professionals
Community referral form for professionals

Community referral form for Professionals

This is a referral form for a community assessment and not for the MBU.

Date of referral Required

DateTime (Hours):Time (Minutes)

Routine or Urgent (please note we aim to offer routine assessments within 4 weeks and we offer urgent assessments within 7 working days). Required

If Urgent, please provide further details

Patients consent has been obtained Required

Please select the reason(s) for referral Required

Pre-conception counselling for those with existing serious mental illness

Women & birthing people who have developed significant mental health difficulties, after the first trimester in pregnancy or following delivery that cannot be managed in primary care

Diagnosis of serious mental illness such as bipolar affective disorder, schizophrenia, severe depression, or anxiety disorder

Previously under the care of perinatal mental health services

Previous admission to a psychiatric unit

First degree relative with bipolar disorder or serious postnatal illness (mother, father, siblings)

Significant disorders of bonding and attachment

PTSD symptoms following loss or birth trauma (from 4 weeks post birth)

Maternal Mental Health Service

Loss of pregnancy due to miscarriage or termination (from 4 weeks post loss)

Stillbirth (from 4 weeks post loss)

Loss of baby within 28 days following birth or following admission to neonatal unit

Primary or secondary Tokophobia

Please complete the following with the MOTHER'S details, not the baby's details.

Mother's title Required

Mother's first name Required

Mother's last name Required

Mother's date of birth Required

Date

NHS number Required

Mother's address Required

Address 1

Address 2

City

Country

State/Province

Postal Code

GP surgery name Required

GP address Required

Address 1

Address 2

City

Country

State/Province

Postal Code

Mother's contact number Required

Pregnancy status Required

Antenatal (currently pregnant)

Postnatal (had a baby within the last 24 months)

If currently pregnant, how many weeks?

If postnatal, what is the babies date of birth?

Date

What is the reason for the referral? Required

Does the mother have any physical difficulties or disabilities we may need to know about? (e.g. hearing problems, visual impairments, mobility issues). If yes, please give further details.

Does the mother require any specific help to communicate with us (e.g. interpreting, Braille)

Does the patient have parental responsibility? (If antenatal is it assumed patient will have parental responsibility?) Required

If no, who has parental responsibility?

Any past or current safeguarding concerns? Required

Has a referral to Children’s Services been made? (If yes, please give details of the Team referred to and the date referral was made) Required

If yes, please add further details including date referral made.

Name of referrer Required

Is there a Child Protection Plan/Child in Need plan in place? If Yes, please provide further details below Required

If there is a Child Protection Plan, Working Agreement or Court Directive please give details including what category the child(ren) is/are registered under and provide a copy of the document if possible.

Current concerns / reason for referral (to include relationship with infant or expected baby/level of functioning with regards to infant care or degree of distress and level of functioning following loss / trauma)

Current and past psychiatric history (Including risk to self/others)

Obstetric history (Please include information on live births as well as previous loss: miscarriage/medical termination, stillbirth, neonatal loss, birth trauma, Tokophobia, and fertility treatment)

Role of the referrer Required

Address or healthcare setting of referrer Required

Address 1

Address 2

City

Country

State/Province

Postal Code

Contact number of referrer Required

Email address of referrer Required

Medical history (please include past and current history)

Privacy Policy Required

I agree to the privacy policy

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