Patient Details

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Is the patient happy to be contacted by phone? Required
Is the patient aware of and agreeable to referral? Required
Does the patient need an interpreter? Required

Healthcare Professionals

Enter the details of the healthcare professionals involved below.

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Is the GP aware of the referral? Required
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Is the named midwife aware of the referral? Required
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Is the health visitor aware of the referral? Required

Any other professionals

Enter the details of any other relevant professionals below.

Are they aware of referral?

Antenatal

Planned pregnancy

Pregnancy loss

Previous loss

Post natal

Mental health

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Is the patient breastfeeding?

Additional information

Is the patient agreeable to being seen at home?

Referrer details

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Please note we can only accept referrals for patients who are up to 12 months postnatal and meet at least one of the criteria below. If you would like to discuss a referral please contact the duty worker on 0191 246 7400.

Pre-Pregnancy Planning Advice
Current or previous diagnosis of bipolar disorder, eating disorder, schizophrenia, schizoaffective disorder or severe depression previously under the care of a secondary care mental health team and planning pregnancy Refer to Perinatal CMHT – pre-conceptual advice 
Pregnancy
Depression and anxiety disorders including, OCD, generalised anxiety, health anxiety, social phobia, panic disorder and agoraphobia in the absence of intent to harm self.  Refer to IAPT Services/ GP
Family history of bipolar disorder in first degree relative In absence of personal illness, ensure close monitoring by maternity and GP
Depression or anxiety where first line interventions in primary care have been attempted and were unsuccessful in the absence of intent to harm self  Refer to  IAPT
Drug or alcohol misuse in absence of primary mental health difficulties Refer to substance misuse services
Previous under care of psychiatrist or secondary mental health team Discuss with Perinatal Duty Worker
Previous inpatient mental health care/ patients discharged from Mother and Baby unit Refer to Perinatal CMHT
Require specialist prescribing advice for psychiatric medications Refer to Perinatal CMHT
Pre-existing bipolar disorder, schizophrenia, postpartum psychosis or other psychotic illness Refer to Perinatal CMHT
Current Suicidal ideation or self- harming behaviours Refer to  Perinatal CMHT / liaise with Duty Worker
Postpartum
Depression and anxiety disorders including, OCD, generalised anxiety, health anxiety, social phobia, panic disorder and agoraphobia in the absence of intent to harm self. Refer to IAPT Services/ GP
Depression or anxiety where first line interventions in primary care have been attempted and were unsuccessful Refer to IAPT Service 
Postpartum psychosis or other psychotic illness Refer to Perinatal CMHT
Breastfeeding mothers who require specialist prescribing advice Refer to Perinatal CMHT
Maternal mental health impacting on mother and baby bonding Refer to Perinatal CMHT
Patients discharged from Mother and Baby unit Refer to Perinatal CMHT
Current self-harming behaviours or  regular thoughts of suicide  Refer to Perinatal CMHT / Liaise with Duty worker