Download specialist perinatal mental health service

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