Mother and Infant Mental Health Referral

CONFIDENTIAL
For advice only please contact us via telephone on 01622 722321 or fax 01622 729677
Completed referral forms can be sent via internal post to MIMHS at 22 Oakapple Lane, Maidstone, ME16 9NWor email:
MIMHS criteria as well as further information regarding our service can be found at
Personal details (please enter details legibly in block capitals
Title: / NHS No:
First Name: / Surname:
Date of Birth:
Address:
Postcode:
Is this address permanent? / Yes / No
Daytime telephone no: / Mobile telephone no:
Marital Status: / Ethnicity:
Preferred language: / Interpreter required? / Yes / No
GP details (please enter details legibly in block capitals)
Name:
Address:
Post code:
Telephone: / Fax:
Referrer details (please enter details legibly in block capitals)
Name:
Address:
Post code
Telephone: / Fax:
Email Address:
Reason for referral (brief summary of problems)
Is the patient aware of this referral? / Yes / No
Attitude to referral: (e.g. what does she want/expect from referral)
Obstetric history
Obstetrician: / Named midwife:
EDD: / DOB of baby: / G / P
Health Visitor details:
Name:
Address:
Postcode:
Telephone: / Fax:
Children:
First Name / Surname / Sex / DOB / Living where / Who with
Y / N
Any past or current concerns including Child Protection?
Has a referral been made to Children & Family Social Services?
Psychiatric history / ( if yes, no if no, n/k if not known)
Bipolar disorder / Schizophrenia / Schizoaffective disorder
Puerperal Psychosis / Depression / Moderate/severe anxiety disorder
Personality disorder / Eating disorder / Substance misuse
Other (please give details) / Family history of severe mental illness
Medical history(if yes, no if no, n/k if not known)Include detials of allergies, relevant personal or familymedicalhistory)
Medical problems / Details:
Currently taking medication
Social stressors(detail problems in the areas listed, i f yes, no if no, n/k if not known)
Stillbirth/ late miscarriage/traumatic birth / Details:
Employment
Financial/debts
Housing/homelessness
Relationship with partner
Relationship with family
Formal risk assessment(detail any evidence of risk in the areas listed,  if yes, no if no, n/k if not known)
Risk to others (incl. children) / Details:
Risk of self-harm
Self-neglect
Vulnerabilitye.g. Learning Disability or adolescent
Child protection concerns
Suicidal ideation with intent/plan
Domestic violence
Attitude towards pregnancy:
Care coordinator
Local Responsible Consultant Psychiatrist
Signature of referrer / Date:
FOR MIMHS USE ONLY: / (Delete as appropriate)
Area:
Appropriate for service:
Allocate to:
Admin Completed: / East Kent/West Kent/DGS
Yes/No (If N admin DC ref. If Y admin allocate)
Clinicians Name(s): ……………………………………………………………
Yes / No /