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Sussex Partnership A teaching trust of Brighton and Sussex Medical School NHS Foundation Trust BRIGHTON and HOVE PERINATAL MENTAL HEALTH SERVICE REFERRAL FORM Women who need URGENT assessment within 4 hours should be referred to MHRRS [Telephone 242220] The Service does not care co-ordinate – but can offer a response to a referral within 5 days if marked PRIORITY. Routine response time is within 28 days of receipt of referral. Women with mild to moderate symptoms of depression and anxiety should be referred to their own GP and/or the Brighton and Hove Wellbeing Service. Please do call the service on 07808632004 to discuss making a referral or to access advice. Please tick ONE of the referral reasons below for a review by the Perinatal Clinic, for advice and an assessment and treatment plan Prescribed mood stabilising or antipsychotic medication and requesting preconception advice Primary tocophobia [fear of childbirth not linked to previous traumatic birth] Past or current history of severe mental illness [e.g. bipolar, schizophrenia or severe depression] Personal or family history of puerperal psychosis or severe postnatal depression Yes No Has patient given consent for this referral Registered GP: PLEASE REPLY TO: Referred by: Contact number email address: or Date of referral: PATIENT DETAILS GP DETAILS Name: Name: Address: Postcode: Practice Address: Postcode: Home Tel: Telephone: Mobile Tel: Fax: Email address: D.O.B: NHS Number: Gender: Ethnicity: Next of Kin: Perinatal Referral Form – Sept 15 Registered Practice: (if different) Sussex Partnership A teaching trust of Brighton and Sussex Medical School NHS Foundation Trust Preconception Prenatal Postnatal Currently: Expected Delivery Date: Delivery Date: History of severe mental illness in the perinatal period YES NO Diagnosis: History of severe mental illness outside of the perinatal period Diagnosis: Current medication: Medical History: Open to ATS Team: YES NO Care Coordinator: Reason for referral: Presenting Symptoms: Identified Risks: Current Mental State: (cut and paste if letter is more appropriate) Health Visitor Name: Contact Number: Address: Midwife Name: Address: Perinatal Referral Form – Sept 15 Contact number: YES NO Sussex Partnership A teaching trust of Brighton and Sussex Medical School Social Worker NHS Foundation Trust Name: Address: Contact number: THE CLINIC MAY MAKE INITIAL CONTACT BY TELEPHONE: Which number(s) is best to reach the Home Mobile patient on? What time is most Office hours Early evening convenient to call? Has patient given consent to leave a Yes No message? Has patient given consent for text Yes No messages? Is it ok to contact carer if patient Yes No cannot be contacted directly? If YES please provide contact details Information for GPs: For Brighton and Hove women: send form via OPTUM Information for Midwives / Health Visitors: Send Brighton & Hove referrals to Connie Sellings Perinatal Mental Health East Brighton CMHT Elm Grove Brighton BN1 3RJ Fax:01273 267551/664732 Mob: 07808632004 [email protected] [email protected] [email protected] Send East & West Sussex referrals to: Nicola Harris Perinatal Mental Health Arun House 16 Liverpool Gardens Worthing BN11 1RY Fax: 01903 823850 Tel: 01903 843538 Mob: 07738758227 [email protected] Perinatal Referral Form – Sept 15 Other please state Other please state