Coastal West Sussex - SPMHS - Referral Form

Information for Referrer:

Routine response time: 20 working days of receipt of referral. Priority referrals: 5 working days.

We welcome discussion of referrals and requests for advice. Please contact SPMHS on 0300 304 0214, who can put you in touch with a practitioner in your area.

Women with mild to moderate symptoms of depression or anxiety (who are managing daily life and do not have areas of high risk) should access support in the first instance through their own GP and/or primary care psychology services:

West Sussex – Time to Talk
(Sussex Community NHS Trust)
Psychological therapies and other community services for West Sussex

South Locality: 01903 70 35 40
(Shoreham, Lancing, Worthing Littlehampton)

West Locality: 01243 81 25 37
(Bognor, Arundel, Chichester, Southbourne, Midhurst, Petworth, Pulborough)
https://www.sussexcommunity.nhs.uk/timetotalk

Website: https://www.sussexpartnership.nhs.uk/perinatal

Prescribing guidelines can be accessed here: https://tinyurl.com/perinatalprescribing

To send referrals:
Specialist Perinatal Mental Health Service,
Estates & Facilities Building
Swandean
Arundel Road
Worthing
West Sussex
BN13 3EP

Mainline Telephone Number: 0300 304 0214
Mobile: 07388 994062
Referrals email: spnt.perinatalreferrals@nhs.net

Disclaimer: Please be aware that sending by email from iCloud, Gmail, Hotmail, Live, Yahoo or other private email accounts to NHS.net is not secure. If you would prefer to send the referral form via post please send it to the above address.

Coastal West Sussex - SPMHS - Referral Form

Referral Details:

Referrer Name:*

Please choose ONE of the referral criteria for assessment by the perinatal team:

Prescribed mood stabilising or antipsychotic medication and requesting preconception advice.

Primary tocophobia (fear of childbirth not linked to previous traumatic birth)

Past history of severe mental illness (e.g. bipolar, schizophrenia or severe depression)

Current symptoms of severe mental illness [e.g. bipolar, schizophrenia or severe depression] and/or not responding fully to treatment in the community and/or areas of high risk (please circle any which apply)

Personal/family history (please circle which) of postnatal psychosis or severe postnatal depression (e.g. requiring admission or secondary care)

Neonatal loss/stillbirth (24wks to 28 days post birth)

Referrer Role:

Location:

Contact Number:*

Email Address:*

Reply To (If Different):

Please confirm your email address:

Has patient given consent for the referral?*

Yes

If not, consider anonymised discussion with a practitioner for advice

Is the Patient:*

Preconception

Antenatal

Postnatal

Being referred for neonatal loss/stillbirth pathway (24wks to 28 days after birth)

Expected Delivery Date: Day*

Expected Delivery Date: Month*

Expected Delivery Date: Year*

Where are they expecting to deliver:*

Where did they deliver:*

Actual Delivery Date: Day*

Actual Delivery Date: Month*

Actual Delivery Date: Year*

Name of Child:*

Date of delivery: Day*

Date of delivery: Month*

Date of delivery: Year*

Patient Demographics:

Name:*

D.O.B: Day*

D.O.B: Month*

D.O.B: Year*

NHS Number:*

Ethnicity:*

Address:

Postcode:

Home Tel:

Mobile Tel:

Consent to leave voicemail?*

Yes

Consent for text messages?*

Yes

Email Address:

Any Other Children:

Access needs including disability/interpreter services:

Is the patient an ex-member of the British Armed Forces or dependent on such a person?*

Yes

Professionals Involved:

GP:

Surgery:

Midwife:

Base:

Health Visitor:

Childrens Centre:

Social Worker:

Hub:

Reason for Referral:

Reason for Referral:*

Is there a known diagnosis/historical mental illness?*

Is the patient open to a mental health team?*

RISK:*

Safeguarding:*

THINK FAMILY: Any safeguarding concerns?

Current medication:*

Relevant medical/obstetric history:*

Any other specialist teams involved:*

Terms & Conditions:

On receipt of the referral it will be allocated to the appropriate locality. Please click here for more information. If you would like to discuss your referral directly with the teams please call;

East Sussex

0300 304 0212

Brighton & Hove

0300 304 0097

North West Sussex

0300 304 0213

Coastal West Sussex

0300 304 0214

You may also email us at spnt.perinatalreferrals@nhs.net

For more information on how information is used, please see our privacy policy.

I have read and agree with the above terms and conditions.*

In Crisis Referrals

Chichester Assessment & Treatment Service
Tel: 01243 62 33 55 – Urgent Referrals
Tel: 01243 62 33 59 – Non Urgent Referrals
(Bognor, Arundel, Chichester, Southbourne, Midhurst, Petworth, Pulborough)
Please Note: Referrals must come via GP

Worthing Assessment & Treatment Service
Tel: 0300 304 0057 (Mon-Fri 9am-6.30pm)
Out of Hours: GP should contact on call Psychiatric Team or A&E
(Shoreham, Lancing, Worthing, Littlehampton)
Please Note: Referrals must come via GP

Coastal West Sussex - SPMHS - Referral Form

Information for Referrer:

Coastal West Sussex - SPMHS - Referral Form

Referral Details:

Patient Demographics:

Professionals Involved:

Reason for Referral:

Terms & Conditions:

Crisis Information: