Perinatal mental health referral form

Please complete all sections. Failure to complete may result in a delay in your referral being processed.

Please indicate whether you feel that this referral warrants immediate attention (classified as emergency), a routine review, or whether it is non-urgent by marking the appropriate box. *
Has the client been made aware of this referral?
Type *
Which maternity unit is booked for the delivery of the baby?
Is an interpreter required? *
Can client be visited by a lone worker?
Drug, alcohol, forensic history
Please tick if you are happy for us to forward referral on to services within Dorset healthcare e.g. Steps to wellbeing, who we may feel your current situation would be better treated