Form Page | Gloucestershire Health and Care NHS Foundation Trust

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Please ring the team directly if an urgent response is required. If a women needs to be seen the same day please contact Crisis Team on Dial 111 and select option 2.

For advice and guidance ring or email the Perinatal Team on 01452 894 952 or E : Perinatal.Referrals@ghc.nhs.uk

Client's details

Name

First Last

Date of birth

If under 18, please refer to CAMHS

NHS Number

Address *

Street Address Address Line 2 City ZIP / Postal Code

Contact number *

GP Name *

GP Address *

Street Address Address Line 2 City ZIP / Postal Code

Relationship status *

Ethnic origin *

Interpreter required? *

Yes

Which language? *

Dependant's details

Baby's name

First Last

Baby's date of birth

Other dependants

Please add name(s) and date(s) of birth of any other children

Obstetric details

EDD *

Parity

Preference for delivery *

Gloucester

Cheltenham

Stroud (midwife led unit)

Home

Other

Professionals involved

Please give names and contact details

Midwife

Consultant O&G

Health visitor

Consultant psychiatrist

Others

e.g social services

Reasons for referral to the perinatal psychiatry service and current mental state (how is the client now?)

Physical health and current medication

Risk history (risk to lone workers , to others, to self, forensic history, safeguarding etc)

Referrer details

Your name *

First Last

Job title *

Your contact number *

Your email address *

Please note: if you have a secure email address, we can send you copies of the assessment and other relevant correspondence to enclose in the medical notes, provided that the patient gives informed consent to share information.

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