URN:
*25206*
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URN:
Family name:
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Given names:
ACT Health
Date of Birth:
Gender: (Select)
Perinatal Mental Health
Consultation Service Referral Form - eNote
Email form to PerinatalMHCS@act.gov.au or
Fax referral to Perinatal Intake - 02 6205 2627
The consultation service provides specialist opinion for pregnant and postnatal women (up to 12
months postpartum) who are experiencing mental health issues. The more comprehensive information
that you can provide will assist us to process your referral in an appropriate and timely manner.
Key Client Details
Is the client aware of the referral?
Yes
No
Perinatal Mental Health Consultation Service can only accept referrals where the client is aware
CALD
Interpreter required Language:
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
Address:
State: (select) Post code:
Phone: (home):
(mobile):
(email):
Is it ok for our service to leave a voice mail or message?
Yes
No
Preferred contact method:
Antenatal
Gestation:
Postnatal
Age in weeks:
EPDS Score:
Name of infant:
Psychosocial Risk Assessment:
Yes
No
If either have been completed please provide a copy
Breastfeeding:
Yes
No
Other Children (names and ages):
Next of Kin:(name):
Relationship:
Partner:
Phone:
GP (name):
Phone:
GP (practice name):
Referrer Details
Date of referral:
Referrer (name):
Service:
Contact details:
Name:
Phone:
Fax:
Email:
Alternative contact
Name:
Phone:
Fax:
Email:
Reason for Referral:
25206(0216)
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URN:
Psychiatric assessment and diagnosis
Medication review (in pregnancy & breastfeeding)
Treatment planning and recommendations
Mother / Infant Assessment / Intervention
Referrer consultation and support
Other Services Involved
Other services involved (service, worker, contact number):
Presenting Issues and Past History
Signs / symptoms of mental health problems (please tick, then describe in more detail below)
Sleep disturbance
Appetite disturbance
Weight loss (without dieting)
Depressed / irritable mood
Difficulty concentrating
Loss of energy
Loss of motivation
Loss of pleasure
Social withdrawal
Excessive self-criticism
Feelings of hopelessness
Feelings of worthlessness
Suicidal thoughts
Intrusive / distressing thoughts
Obsessive / unrealistic fears
Repetitive rituals (e.g. checking, counting, cleaning)
Avoidance of specific situations
Anxious thoughts / worries
Somatic anxiety (breathlessness, palpitations)
Nightmares / flashbacks
Bizarre ideas and beliefs (i.e. delusions)
Hallucinations (auditory / visual etc)
Periods of elevated / elated mood
Disinhibited / risk taking behaviours
Strange or incoherent speech
Please provide information about above symptoms including duration, intensity and frequency:
Impact on functioning, parenting capacity and ability to carry out daily tasks:
History of mental health problems (including current and past diagnoses, admissions and treatments):
Precipitants and Stressors
Include factors that may have contributed to the onset, exacerbation or maintenance of the mental
health problems:
Medications (current and past)
Medication
Date prescribed
Dose
Duration
Reason
Doctor
Risk Issues & Concerns
Are there any current safety concerns for the person or the infant?
Risk Factors: (please tick)
Protective Factors: (please tick)
History of suicidal ideation / self harm
Personal coping skills
Current suicidal ideation / self harm
Moral / religious values that oppose suicide
Thoughts of harm to others including infant
Self-esteem
Depression high EPDS
Connectedness and social support
Other diagnosed mental illness
Seeking help and support
Isolation from family / peers
25206(0216)
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URN:
Recent stress crisis
Substance abuse
details:
Adverse social circumstances
details:
Family history of mental illness
details:
History of violence
details:
Concerns about violence in the home
details:
Comments / details
Useful questions to assess harm to self:
“Some mothers when they are depressed / distressed
experience thoughts about harming themselves”….
Useful questions to assess harm to the infant:
“Some mothers experience negative thoughts about
their baby?
Question - Have you had thoughts of harming
yourself / ending your life?
If yes…
 Did you think of a way to do it?
 Do you wish you were dead?
 How close have you come to doing it?
 Do you wish you wouldn’t wake up?
 Can you give me more details?
 What has stopped you from acting on these
thoughts?
Question – Have you had any thoughts about
harming your baby?
If yes…
 Have you made any plans to harm your baby
or are they ideas / images?
 Can you give me more details?
 Have you attempted to harm your baby?
If yes, when?
 Do these thoughts distress you?
If you have any concerns about the immediate safety of the client or their infant it is important
that you contact the Mental Health ACT, Crisis Assessment Treatment Team to discuss whether
a more urgent mental health assessment is appropriate
CATT – 1800 629 354 (24 hours)
Additional Information
Is there any further relevant information?
If you have any queries about the referral processes please contact the Perinatal Mental Health
Consultation Service on 620 51469. You will receive feedback about the outcome of this referral.
25206(0216)
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