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Refer to the Perinatal Mental Health Team

We ask that you call to discuss your referral prior to sending this information to our Perinatal Mental Health Team. You can call us on (01482) 336837 and the service operates Monday to Friday, 9am to 5pm.

If you are unable to call first and feel this referral is urgent, please be aware there will be no-one available to respond outside of office hours and you should contact your Single Point of Access or Hospital Liaison team.

Please complete all fields of the below form as it may not be processed if there is missing information. Only referrals received on this form will be processed and other documentation should only be sent as supplementary to this.

Referrer Details

Name Required

Role Required

Telephone number Required

Email address Required

Address Required

Is the person aware of and consenting to this referral? Required

Yes

Does the patient agree for their referral to be discussed with other relevant professionals to ensure they receive the most appropriate service? Required

Yes

Are there preferred days, times or methods to contact the person? If so, please include these below.

GP details

Name Required

Practice name/address Required

Telephone Required

Names and details of other professionals involved

The person being referred

Name (including title and preferred name) Required

NHS Number Required

Date of birth Required

Address Required

Home number

Mobile number

Is it OK to leave a message?

Yes

Ethnicity

Self-identified gender/Chosen pronouns

Spoken language/sign language

Sexual orientation

Marital status

Do you need an interpreter or sign language user?

Yes

Employment status

Religion

Is this person in the armed forces or ex-armed forces?

Yes - current

Yes - ex-armed forces

Accommodation status

Date of birth or estimated delivery date of baby Required

Who has, or will have, parental responsibility? Required

Please enter the names and dates of birth for any other children for who this person has parental responsibility

Are there any children not in the care of this person? Required

Yes

Are children's social care involved? Required

Yes

Please detail any current or previous children's social care involvement.

Next of kin/significant other

Name Required

Relationship Required

Address Required

Contact number Required

Is the person being referred happy for us to contact the next of kin/significant other? Required

Yes

Reason for referral

Please detail current presentation, including signs of poor mental health or distress, any mental health treatment being provided and any physical health, social, relationship or substance misuse factors contributing to the situation. Required

If present, please detail concerns relating to risk, nature of risk, who risk is to and who it's from.

Does the person being referred or significant others have a different view of the situation or risk? Required

Does the referrer have any concerns about the attachment/bonding between the person being referred and their (unborn) baby? Any concerns around how they are coping with being a parent?

Has a safeguarding referral been considered? Required

Historical mental health involvement, treatment or interventions and risk

Current or historical obstetric complications and risks

Any other physical health complications or risks, including allergies?

Prescribed medication (please provide all current medications and any previous medications for mood or psychosis)

Is there any other information you feel is important to the referral?

Please indicate which treatment pathways you feel would be appropriate for the person being referred - preconception counselling, specialist assessment, urgent assessment, psychological interventions (including which ones) or admission to Mother/Baby unit Required

Does the person being referred/ their significant others have differing ideas about what treatment would be helpful?

Please read and agree to the terms of the above privacy policy Required

I agree to the privacy policy

NAViGO Health and Social Care CIC. Registered in England and Wales.
Company Registration No: 07458926.
Need help now? Call 01472 256 256 or freephone 08081 968442

Registered Office: Navigo House, 3 – 7 Brighowgate, Grimsby, DN32 0QE
Telephone: 01472 583000
Fax: 01472 583000 / Email: info.navigo@nhs.net