Specialist Perinatal Service and Maternal Loss Psychology Service referral form

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For the Specialist Perinatal Mental Health Service Referrals – All referrals treated as routine unless otherwise advised – with the service providing telephone triage within 2 working days.

Please call SPMHS (03000 270480) if referral requires an urgent or emergency response.

Section 1 - Referrer details

*First name:

*Last name:

*Job title / profession:

*Telephone number:

*Email:

*Address and postcode:

GP: Address and postcode:

GP: Telephone number:

*Is the GP aware of this referral?

*Are there any other services involved?

Please include their addresses and telephone details.

*What service do you want to make a referral to?

Section 2 - Patient Details

*First name:

*Surname:

*Date of Birth

*Gender:

Email address:

NHS number (if known):

*Telephone:

*Address and Postcode:

Accommodation status:

*Ethnicity:

*Religion:

*Marital status:

*Employment status:

*Interpreter needed?

*Preferred language:

*Next of Kin / Partner / Emergency contact - Relationship and telephone:

*Is this referral for yourself?

Section 3 - Consent

Consent must be sought to share personal information with Northamptonshire Healthcare NHS Foundation Trust and other organisations that can offer support relevant to this referral

*Tick this box to confirm that consent has been discussed and received

Section 4 - Patient Medical Information

We advise that referrals are made following the initial dating scan. Referrals made prior to this may be offered medication advice only.

*Is the service user currently pregnant?

If yes, what stage are they in their pregnancy? Have they had an initial dating scan? What is their EDD (estimated date of delivery)?

If no, have they given birth? What is the name and date of birth of their baby?

*Have they experienced pregnancy loss?

Pregnancy Loss Details:

*Obstetric history (please include current and historic contact with maternity services including deliveries, stillbirths, miscarriages and terminations)

*Does this service user have other children?

First Name	Surname	Date of Birth	Date of Death (if applicable)	Gender	Where are they living?

Section 5 – Reason(s) for referral (Specialist Perinatal Mental Health Service)

Specialist Perinatal Mental Health Service: The service supports women at preconception stage or that are currently pregnant who have moderate to severe mental health conditions including bipolar disorder, psychosis, depression, anxiety and OCD. The service works with women and their babies during the perinatal period

*If you are referring to the Specialist Perinatal Mental Health Service, please select one of the options:

Referral Reason Priority	Referral Reason
1st Reason

Reasons for referral and any additional relevant information

Section 6 - Reason for referral (Maternal Loss Psychology Service related)?

Maternal Loss Psychology Service: The service supports women experiencing moderate/ severe mental health difficulties (e.g. PTSD) relating to baby loss (including still birth, neonatal loss, miscarriage(s) and complex fertility).

If you are referring to the MLPS, please select the main reason for your referral:

Summary of reason(s) / any additional relevant information (Including any significant mental health difficulties):

*Do they have any past psychiatric history?

If Yes please specify from the list

Psychiatric History Priority	Psychiatric Condition
1st Condition

Please provide any additional information. Please ensure that you include all relevant information including diagnosis, past psychiatric admissions, history of relapse, psychiatric medication including names, dosage, date of last review and compliance:

Provide details of any relevant family psychiatric history

Provide details of any relevant physical and medical history

Tell us what their attitude is to their current pregnancy or to their baby if born:

PHQ-9 Depression score:

PHQ-9 Q9 score (options 0,1,2 or 3):

GAD-7 Anxiety score:

*Current or historic safeguarding concerns?

If yes, please provide more details including child protection, previous or current child in need (CIN), MASH referrals and details of any allocated social workers:

Are they any risk considerations. Tick all that apply:

Dangerous/Risk to others

Risk of self-harm

Self-neglect

Vulnerability

Domestic violence

Suicidal or self harm

Not Applicable

Are there any additional risk considerations we should be aware of?

Finally, let us know any red flags that require urgent referral. Tick all that apply:

New thoughts of violent self harm

Rapidly changing mental state

Feelings of estrangement from the infant or incompetency as a mother

Not Applicable

Please provide us some more context on additional red flags that you might be aware of:

Attachments

Please upload any other information relevant for this referral. Please note we accept a maximum of 5 documents, with a maximum 5MB per document, please limit to 5MB per document.

Document Name	Upload Docs

Thank you for submitting a referral. Your response has been recorded.

DATA PROTECTION NOTICE

Data that you provide to the Trust is processed in accordance with the Data Protection Act 2018, please see the Trust Privacy Notice for further information on how data is used:

https://www.nhft.nhs.uk/privacy/