Perinatal and Infant Mental Health Service South Western Sydney

Referral Form for health professionals only

Preamble: PIMHS provides support to women who are pregnant (>13wks) or primary carers who have a child under 24 months of age and have a diagnosed mental illness with moderate to severe symptoms.

If current acute mental health risk please refer directly to Mental Health Access Line on 1800 0115 11
Section A: Referrer details 	
Date of referral: <TodaysDate>	Given Names:  <RefName>	
Role: <Referrer role>	Organisation: <Referrer organisation>	
Contact number:  <RefPhone>	Email address: <RefEmail>	
Workplace address:  <RefAddress>	

Section B: Consumer details 	
Perinatal status: <Perinatal status>		
Name: <PtFullName>	MRN: <PtIHI>	
Address:<PtStreet> <PtCity> <PtState> <PtPostcode>	Contact number: <PtPhoneMob>	
Date of Birth: <PtDoB>	Age: <PtAge>	
Gender: <GenderIdentity>	Gravida/Parity : <Gravida/Parity>	
Language spoken at home:<Consumer language spoken at home>	Interpreter required: <Interpreter required>	
Cultural background: <Consumer cultural background>	Country of Birth: <Patient country of birth>	
Aboriginal or TSI:<Consumer Aboriginal or TSI>	Accomodation status: <Accomodation status>	
Maternity Hospital:<Maternity hospital>	EDD: <EDD>	
Consent obtained from consumer and aware of referral	<Patient consent>	
Goals of consumer: <Consumer goals>	
Informal support network 	<Consumer informal support network>	

Section C: Infant details 	
Infant Name (if known): <Infant name>	EDD/DOB:  <Infant EDD/DOB>	
Aboriginal or TSI: <Infant Aboriginal status>    	

Section D: Designated carer and/or next of kin	
Name:<NOKName>	Contact number:<NOKContact>	
Address:<HOFAddress>	Relationship to consumer: <NOKRelation>	

Section E: GP details	
Name:<DrFirstName><DrSurname>	Name of practice:<DrAddress>	
Address:<DrStreet><DrCity><DrState><DrPostcode>	Contact number: <DrPhone>	

Perinatal and Infant Mental Health Service South Western Sydney Referral Form Version 1.0

Section F: Current mental health 	
Reason for referral 	<VisitReason>	
Support requested	<Type of support requested>	
Presenting symptoms	<Presenting symptoms>	
EDS and K10 score	<EDS and K10 Score>	
Goals for referral	<Goals for referral>	
Current services in place	<Current services in place>	

Section G: Mental health history and treatment 	
Mental health history 	<Mental health history>	
Previous treatments	<Previous treatment>	
Family history of mental illness or perinatal mental illness including suicide 	<Family history of mental illness or perinatal mental illness including suicide>	

Section G: Mental health history and treatment 	

History of developmental
trauma	<History of developmental trauma>	IPV 
(Also consider referral to
1800RESPECT/ 1800 737 732)	<IPV>	
History of child protection	<History of child protection>	Current child protection
concerns
(MRG to be completed by referrer,
include engagement/report number)	<Current child protection concerns>	
Maternal history of disrupted attachment	<Maternal history of disrupted attachment>	Legal issues
(AVO’s, family law court, history
of incarceration)	<Legal issues>	
Substance misuse 
(tobacco, alcohol, illicit
substances)	<Substance misuse>	Poor support network	<Poor support network>	
History of aggression or
violence	<History of aggression or violence>	Complications of
pregnancy	<Complications of pregnancy>	
History of birth trauma	<History of birth trauma>	Recent pregnancy loss
	Refer to SANDS 1300 308 307
Red Nose 1300 308 307
  GIDGET 1300 851 758	
History of suicide ideation,self-harm or harm to others	<History of suicide ideation, self-harm or harm>	Current suicide ideation,
self-harm or harm to others	Refer directly to MHAL
1800 011 511	

COMPLETED REFERRAL FORM AND RELEVANT DOCUMENTATION TO BE EMAILED TO:
SWSLHD-PIMHS@health.nsw.gov.au

If you have any questions, please contact the intake officer on 9616 4203

Disclaimer: Completion of referral does not guarantee acceptance to PIMHS. Duty of care remains with the referrer until care is accepted. If acute risk and/or requires contact within two weeks, please refer to the Mental Health Access Line on 1800 011 511. If urgent risk please refer to the emergency services on 000.	

<CurrentRx>
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