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: <<MRN>>	
Address:<PtStreet> <PtCity> <PtState> <PtPostcode>	Contact number: <PtPhoneMob>	
Date of Birth: <PtDoB>	Age: <PtAge>	
Gender: <GenderIdentity>	Gravida/Parity :<<Clinical Details:Gravida>><<Clinical Details:Parity>>	
Language spoken at home:<<Patient Demographics:Language Preferred>>	Interpreter required: <<Patient Demographics:Requires Interpreter>>	
Cultural background: <<Patient Demographics:Ethnicity>>	Country of Birth: <<Patient Demographics:Country of Birth>>	
Aboriginal or TSI: <<Aboriginal or TSI>>	Accomodation status: 	
Maternity Hospital: <<Maternity hospital >>	EDD:<<EDD>>	
Consent obtained from consumer and aware of referral	<<Consent obtained from consumer>>	
Goals of consumer: <<Goals of consumer>>	
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 or TSI>>	

Section D: Designated carer and/or next of kin	
Name: <<Patient Demographics:Emergency Contact>>	Contact number:<<Patient Demographics:Emergency Contact Phone>>	
Address:<<Patient Demographics:Emergency Contact Address>>	Relationship to consumer: <<Patient Demographics:Emergency Contact Relationship>>	

Section E: GP details	
Name:<<Doctor:Name>>	Name of practice: <<Name of practice >>	
Address: <<Doctor:Full Address>>	Contact number: <<Doctor:Phone>>	

Section F: Current 
Perinatal and Infant Mental Health Service South Western Sydney Referral Form Version 1.0
Issued: July 2023mental health 	
Reason for referral 	<<Reason for referral>>	
Support requested	<<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 treatments>>	
Family history of mental illness or perinatal mental illness including suicide 	<<Family history of mental illness>>	

Section H: Psychosocial assessment risk assessment (please write yes/no, if yes please provide comment) 	
History of developmental trauma	<<History of developmental trauma>>	IPV (Also consider referal to 1800RESPECT/1800737732)	<<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>>	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.	

<<Clinical Details:Current Antenatal Visits>>
<<Clinical Details:History List>>
<<Clinical Details:Medication List>>