ROYAL PRINCE ALFRED HOSPITAL	

RPA WOMAN AND BABIES
PSYCHOSOCIAL REFERRAL FORM	

	SURNAME:    <<Patient Demographics:Surname>>                                  MRN	

OTHER NAMES:      <<Patient Demographics:First Name>>                 MALE        FEMALE	

D.O.B.         <<Patient Demographics:DOB>>                                  M.O.	

ADDRESS <<Patient Demographics:Address Line 3>>
<<Patient Demographics:Address>>	

LOCATION	

COMPLETE DETAILS OR AFIX PATIENT LABEL HERE	

Estimated Due Date: <<Clinical Details:EDC>>
GP Details: <<Doctor:Full Details>>	

Referral discussed with client?	
YES □    NO □	

Verbal consent for referral given by client?	
YES □    NO □ ( If declined, why?)	

Verbal consent to discuss with GP?	
YES □    NO □	

Reason for Referral: (tick one or more)
                                           Past / Present                                         Past / Present                                       Past / Present	

Poor support network        □   □	
Depression                                 □   □	
Young parent                           □   □	

Financial Issues                    □   □	
Anxious Mood                           □   □	
Drug health issues                   □   □	

Housing Issues                     □   □             	
Postnatal Depression               □   □	
DOCS involvement                  □   □	

Relationship difficulties      □   □	
Mental Health issues(other)   □   □	
Breastfeeding issues               □   □	

Domestic Violence              □   □	
Childhood Abuse/Neglect       □   □	
Sexual health issues                □   □	

Briefly explanation for the referral and any other relevant information	

	

	

EDS score:	

Referred to:                                                             Date:	
Referred to:                                             Date:	

Social Worker	
Antenatal Support Midwife	

Perinatal Mental Health /mental health liaison	
Perinatal and family drug health	

Early childhood health service	
Lactation	

Referrer:	

Name <<Doctor:Name>>	
Designation	

Signature
	
Date of referral
<<Miscellaneous:Date (short)>>	

Referral taken by_______________________________
(name of clinician)                            Print Name	

Signature                                          Date:	

OUTCOME:	

	

	

	PSYCHOSOCIALREFERRALFORM    MRN4	
Please Fax: 9515 7452
To ensure that the referral has been received, a message can be left with Perinatal Mental Health ph 9515 5873
Or GP Liaison Midwife  ph 0425 230 662