Please note: This website is best viewed in a modern browser like Chrome, Edge or Firefox. We no longer support Internet Explorer 11.

Professional Form Perinatal Mental Health Referral (City and Hackney)

Format: d.m.y
Permanent address?
Interpreter required?
Preferred type of appointment
A copy of your submission will be sent to the email provided.
Is patient aware of referral? (including attitude to referral)
Psychiatric History ( if yes & include further relevant information i.e. diagnosis, past psychiatric admissions, history of relapse)
Psychiatric Medication (include name, dose, date of last review and compliance) (If yes)
Suicide and/or Self-harm (if yes)
Emotional Wellbeing in Past Month (if yes)
Current Mental Health Treatment Provided by (if yes)
Family Mental Health History (if yes)
If female relative, was this in perinatal period?
Please provide details about children including first name, surname, sex, date of birth, where they are living and who with for each child. 
Any past or current concerns including child protection/formal court proceedings (if yes)
If there are child protection/formal court proceedings ongoing, please give details including named workers.
Current social circumstances
Risk assessment
Please include at least two of the following assessments (for Mental Health Services only) if yes
Are you currently pregnant or recently given birth?
Please upload if relevant any of the following: Completed outcome measures e.g. PHQ-9 and GAD-7, Most recent clinic letter, Most recent mental health assessment
Maximum 5 files.
64 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.