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 a decline in their mental health and wellbeing as evidenced by the Edinburgh Postnatal Depression Scale (EPDS).

EPDS # 13-17 or EPDS < 13 and clinical picture indicates need - will be referred to our mild-moderate service

EPDS # 18 or over – will be referred to our moderate-severe service

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
- 0800 653 357 MidCentral DHB Acute Care Team
- 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
Consent to refer has been given by client.
Referred Client Full Name

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

DayMonthYear
Date
NHI Number
Gender
Ethnicity
Home Address

Street Address

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

DayMonthYear
Date
Edinburgh Postnatal Depression Scale (EPDS) Score
Edinburgh Postnatal Depression Scale (EPDS) Assessment Date

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
Other (please specify)
Please describe any disability/accessibility, language or literacy needs (e.g., requires wheelchair, or low vision, english as a second language
Primary Support Person Full Name

First NameLast Name
Primary Support Person Relationship
Primary Support Person Contact Phone
Client's Family Location
Partner's Family Location
Support already in place
GP Name
Practice Name
Other Relevant Information
Scan and upload any additional documents (optional)

Cancelof
Consent to refer has been given by client.
Should be Empty: