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Perinatal Referral Form
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Blackpool Talking Therapies
Service Information
Perinatal
Perinatal Referral Form
Referrers Name
Required
Referrers Service
Required
Referrers contact number
Required
Referrers email
Required
Does the client consent to this referral?
Required
Yes
No
Patient Name
Required
Patient Address
Address 1
Address 2
City
Country
Select a country
United Kingdom
County
Postal Code
Patient Phone number
Patient email
NHS number
Date of birth
Required
GP Practice
Ethnicity
Next of kin / Emergency contact details - Name
Next of kin / Emergency contact details - Relationship
Next of kin / Emergency contact details - Address
Address 1
Address 2
City
Country
Select a country
United Kingdom
County
Postal Code
Next of kin / Emergency contact details - Contact Number
Perinatal Information, If pregnant: Current gestation
Perinatal Information, If pregnant: Expected due date
Perinatal Information, If postnatal: Date of birth of child/ren
Date
Perinatal Information, If postnatal: Any issues with the pregnancy / birth?
Yes
No
Reason for referral / Presenting Problem
Anxiety
Depression
Excessive worrying
Panic attacks
Significant fear of childbirth
Unhelpful or distressing thoughts
Does the patient have any support around their mental health problem? (Already involved with mental health services?) Please give details:
Are there any other services currently involved in the patient’s care? (e.g. Consultant / Specialist Midwife/Health Visitor / Social Services etc.) Please provide details
Does the patient have any difficulties, or social factors, that may impact on them attending / engaging in regular therapy sessions?
Provide details
Are there any risks to be aware of?
First 4 weeks postpartum
Sudden deterioration of mental health
Thoughts of violent method of suicide
Feeling estranged from infant
Thoughts of absconding
Previous history of self-harm/suicide attempts
Thoughts of harm to child
Substance misuse
Please tick the statement below if you give your consent for information to be shared.
I give my consent for the information contained in this referral to be shared with the NHS Blackpool Talking Therapies team.
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