RHW PERINATAL MENTAL HEALTH (PNMH)CLINIC
REFERRAL FORM FAX to: (02) 9382 6421	
Please discuss ALL referrals with PNMH Clinical Midwifery Consultant Ph: 0457733554
Date of referral: <TodaysDate>
Patient details:
Name: <PtName>	DOB: <PtDoB>	MRN: <PtMCNo>
Address: <PtStreet>, <PtCity>, <PtPostcode>
Contact number: <PtPhoneH> , <PtPhoneMob>
Antenatal / Postnatal (circle)			Gestation: _________	 EDC: ______________________
Infant age: __________		Infant DOB: ______________		 Baby born @ RHW YES/NO (circle)
Referrer details: 
Name & Role: <DrName> , GP	Phone: <DrPhone>	Email: ______________________
Reason for referral:		Is this a referral for MH home-visiting service? Y/N (circle)
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Recent EPDS:   ______/30  Q10: _______ Date of EPDS: _________
Past mental health history:			Past Contact with RHW psychiatry Clinic? YES/NO (circle)
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Current Medications: (& recent changes)	Substance use &  Medical history:			
___________________________________	________________________________________
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Other key health care providers:		GP details (Name, address, phone):
__________________________________	________________________________________
Clinic Referral Criteria:-	ANTENATAL: all women birthing at RHW 
POSTNATAL: less than 6 months postnatal AND living in Northern sector SES LHD