Community Perinatal Team (CPT) Professional Referral Form This form is to be used for antenatal and postnatal outpatient referrals from professionals. Details of referrer Patient details / sticker (Please print legibly. We cannot accept referrals without referrer details) Name: Name: Profession: DOB: Address: Address: number: GP Details: Date of referral: NHS number: Routine or (Routine referrals have Phone number (Essential as all referrals receive urgent telephone triage): telephone triage within 2 working days. Please call CPT if referral is urgent): What are the concerns about the patient’s mental health? (Please tick all relevant boxes) Previous postpartum psychosis Bipolar Disorder Birth Trauma Severe depression Obsessive Compulsive Disorder Moderate depression Personality Disorder Severe anxiety disorder Eating Disorder Moderate anxiety disorder PTSD incl Psychosis / Schizophrenia Recurrent self-harm Other (please provide details): Previous Both  Are these problems: Current Please provide details of the concerns: Details of any psychiatric medication:
Community Perinatal Team (CPT) Professional Referral Form This form is to be used for antenatal and postnatal outpatient referrals from professionals. Details of referrer (Please print legibly. We cannot accept referrals without referrer details) Patient details / sticker Name: Name: Profession: DOB: Address: Address: number: GP Details: Date of referral: NHS number: Routine or urgent (Routine referrals have telephone triage within 2 working days. Please call CPT if referral is urgent): Phone number (Essential as all referrals receive telephone triage): What are the concerns about the patient’s mental health? (Please tick all relevant boxes) Previous postpartum psychosis Birth Trauma Bipolar Disorder Severe depression Obsessive Compulsive Disorder Moderate depression Personality Disorder Severe anxiety disorder Eating Disorder Moderate anxiety disorder PTSD incl Psychosis / Schizophrenia Recurrent self-harm Other (please provide details): Are these problems: Current Previous Both  Please provide details of the concerns: Details of any psychiatric medication: