Perinatal Service Referral Form
(Prammbs Northwest )
This service provides assessment and advice and in some cases management for women during the ante-natal
and post-natal period. Who
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Have a past or present diagnosis of schizophrenia, bi-polar disorder, psychosis or severe depression
Have any other severe or complex mental illness, past or present, which requires treatment by a
psychiatrist/specialist mental health team including inpatient care.
And who are pregnant or have a baby under twelve months of age or require preconception advice
For This Referral:
Please attach relevant documents, including risk assessments, out-patient letters, discharge summaries,
and other relevant reports with this referral form
In-patient Referrals
Please forward to: Referral Manager, Andersen Ward, Laureate House, Wythenshawe Hospital, Southmoor
Road, Wythenshawe, Manchester M23 9LT Tel: 0161 291 6828 Fax: 0161 291 6821
Out-patient Referrals:
Please forward to: Secretary to Dr Wieck Consultant Psychiatrist, Laureate House, Wythenshawe Hospital,
Southmoor Road, Wythenshawe, Manchester M23 9LT Tel: 0161 291 6930 Fax:0161 291 6921
Please note: This is NOT an Emergency Service.
Contact GP, local Mental Health Crisis Team or A&E Department in case of emergency
The receipt of this form does not imply that the referral is accepted
Please ensure your client is aware of this referral
Reasons for this Referral:
In-Patient Admission
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Out-patient Appointment
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Clarification of diagnosis
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Pre-conception advice on treatment, including medication
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Medication advice for pregnancy and/or breast feeding
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Care planning and management in the ante-natal period
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Care planning and management in post-natal period
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Have Children & Family Social Services (CFSS) requested a Parental Assessment in postnatal period
(please circle)
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YES
NO
Referrer’s Details:
Name:
Date of referral:
Designation:
Organisation:
Name of PCT
Address & postcode:
Telephone:
Fax Number:
Patient’s Details:
Name:
D.O.B.:
Address & postcode:
Telephone:
Current / previous occupation:
Marital status:
Religion:
Ethnicity:
First language:
Is an interpreter required?
YES
NO
Pregnancy or Delivery:
Expected Delivery Date (EDD) or Date of Birth (DOB) of Child: _______________________________________
Other Children:
Name: ___________________________ DOB: _____________ Resident with: ________________________
Name: ___________________________ DOB: _____________ Resident with: ________________________
Name: ___________________________ DOB: _____________ Resident with: ________________________
Is the unborn child/children currently subject to safeguarding or involvement with Children & Family Social
Services? If yes, please attach details as this will assist the assessment process.
Professional(s) Involved:
Practice Name:
GP’s name:
Obstetrician’s name:
Address & postcode:
Address & postcode:
Telephone:
Telephone:
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Consultant psychiatrist’s name:
Care coordinator’s / Name of Mental Health Staff’
Address & postcode:
Address & postcode:
Telephone:
Telephone:
Health Visitor/School Nurse
Children’s Social Services
Name:
Name:
Address & postcode:
Address & postcode:
Telephone:
Telephone:
Other service
Other service
Name:
Name:
Address & postcode:
Address & postcode:
Telephone:
Telephone:
Current or Past Psychiatric History:
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The patient has a diagnosis / history of severe mental Illness
Please specify:
 Severe Depression
 Schizophrenia or schizo-affective disorder
 Bipolar Affective Disorder
 Other Psychosis
 Personality Disorder
 Other mental health condition : please state:_______________________
Risk
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Risk to Child
Domestic abuse
Alcohol/Drug Misuse
History of use of weapons
Past
Past
Past
Past
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□
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Present
Present
Present
Present
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□
□
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No Risk
No Risk
No Risk
No Risk
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The patient has a history of previous treatment by a psychiatrist specialist mental health team (including
inpatient care). Please attach information. Please note that the provision of information on the woman’s
past and current mental health will assist with the assessment process.
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Details of Presenting Issues:
Please give information on the following:
1. Presentation
2. Current treatment
3. Hallucinations or delusions regarding infant or children
4. Current concerns
5. Mental Health Act (MHA) status
6. Current contact with baby
7. Other relevant information
Current Physical Status:
Please list all the physical problem(s) known:
Known current infection(s):
Please list all medication(s) the client is taking:
Known allergies:
In-patient Referrals
Tel: 0161 291 6828 Fax: 0161 291 6821
Out-patient Referrals
Tel: 0161 291 6930 Fax:0161 291 6921
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