Strong Beginnings Perinatal & Postpartum Treatment Group Referral

Strong Beginnings Perinatal & Postpartum Treatment Group Referral
Strong Beginnings is designed to support the one in seven women who will experience depression and other mood and anxiety disorders before, during and after pregnancy. Through screening, and peer-to-peer support, this program reaches both pregnant and postpartum mothers and promotes healthy moods, stress management, and bonding strategies with babies. Free Emotional Virtual Support Groups for pregnant women, and women struggling with mood and anxiety issues during and after delivery. Please fill out this form as best you can so we can provide you with the most relevant service.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Referral Source*

ChildNet//DCFCourtSchool/Day Care211/Help Me GrowSelfOther
Referral Source Email*
example@example.com
Referral Source Phone Number*
Please enter a valid phone number.
Client Name*

First NameLast Name
Client DOB*

MonthDayYear
Date
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Email
example@example.com
Client Phone Number*
Please enter a valid phone number.
Has the Client Participated In Mamas Circle or Strong Bebinnings within the past 12 months?*
Preferred Language*

EnglishSpanishHaitian CreoleOther
Race*

American IndianAfrican American/BlackAsianHawaiian/Pacific IslanderWhiteMulti-RacialOther
Ethnicity*

HispanicNon-HispanicAfro CaribbeanHaitian
Married?*
Verbal Consent for Referral?*
Reason for Referral
Eligibility

Pregnant or have a child under the age of 1-year oldPresenting with symptoms of depression/anxiety for more than 2-weeks
Risk Factors

Maternal DepressionAnxiety (numbness, unable to relax, constant worry, etc)Prior mental health diagnosisPoverty or economic distressEarly Pregnancy or unplanned pregnancyAce Score of 4 or moreNegative event within the last yearPremature birth, low birth weight or other serious birth complicationsLack of social network
Score on EPDS*
Current Drug/Alcohol Usage?*
Previous/Current Psychiatric Diagnosis*
Comments
Signature

Clear
Date

MonthDayYear
Date
Referral Agency*
The below section is to be completed by the Journey Institute staff only.
Status of Referral
Assigned Clinician
Date Assigned

MonthDayYear
Date
Service Start Date

MonthDayYear
Date
Notes
Should be Empty: