The Hope Collective Health Provider Perinatal Mental Health Referral Form

The Hope Collective Health Provider Perinatal Mental Health Referral Form
This service is for Pregnant Women/Birthing Parents experiencing Mild to Moderate Decline in Mental Well Being as evidenced by the Edinburgh Postnatal Depression Scale (EPDS) with scores as below:
- EPDS# 13-17 or
- EPDS# <13 and clinical picture indicates need
Edinburgh-postnatal-depression-scale
- We are not a crisis service and do not have after hours or weekend services.
- For urgent or crisis mental health care call 111
- We aim to contact all our referrals within three business days
Referral Date*

DayMonthYear
Date
Referrer Full Name*

First NameLast Name
Referrer Contact Phone*
Referrer Email Address*
example@example.com
Referred Client Full Name*

First NameLast Name
Referred Client Contact Phone*
Referred Client Email Address*
example@example.com
Referred Client Date of Birth*

DayMonthYear
Date
Referred Client NHI Number
Referred Client Gender
Referred Client Ethnicity
Referred Client Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Pregnancy Status*
Expected Delivery Date (if pregnant)

DayMonthYear
Date
Other information
Number of Dependants
eg 3
Ages of Dependants (if applicable)
Reason for Referral*
Relevant Previous or Existing Mental Health and Physical Challenges*

No previousPerinatal Anxiety and/or DepressionPregnancy challenges such as hyperemesis, diabetes, preeclampsiaPrevious stillbornPrevious birth trauma / birth injuryFertility challenges / IVFDepressionAnxiety and/or Panic AttacksOCDBipolar DisorderPTSDPsychotic EpisodeEating DisorderBorderline Personality DisorderAddictionNeurodivergentUnsureOther
Other (please specify)
Please describe any disability/accessibility, language or literacy needs (e.g., requires wheelchair, or low vision, english as a second language
Edinburgh Perinatal Depression Scale (EPDS) Score*
Edinburgh Perinatal Depression Scale (EPDS) Assessment Date*

DayMonthYear
Date
Primary Support Person Full Name

First NameLast Name
Primary Support Person Relationship
Primary Support Person Contact Phone
Please enter a valid phone number.
Client's Family Location

Same townSame districtNZOverseasNo support
Partner's Family Location

Same townSame districtNZOverseasNo support
Support already in place*

General PractitionerPlunketRaukawa Whanau Ora (Horowhenua / Manawatu)Best Care Whakapai Hauora (Manawatu)Te Waka Huia (Manawatu)Te Kete Hauora (Tararaua)Public Health (extreem rural Tararua)Te Koutuku (Rangatikei)Community Mental Health ServiceMaternal Mental Health ServicePrivate Specialist eg Psychologist, Counsellor,
GP Name
Practice Name
Other Relevant Information
Scan and upload any additional documents (optional)

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