North 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 0213, 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:
Women can now self-refer to Time to Talk by calling 01403 620434 or they can be referred by their GP. More information is available at www.sussexcommunity.nhs.uk/t2t

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,
Sussex Partnership NHS Foundation Trust,
1-7 Station Road,
Crawley,
West Sussex,
RH10 1HT

Mainline Telephone Number: 0300 304 0213
Mobile: 07388 228048
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 to above address.

North 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 after 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

Horsham Assessment & Treatment Service: 0300 304 0021
Crawley Assessment & Treatment Service: 01293 652300
Mid Sussex Linwood 01444 416606

North West Sussex - SPMHS - Referral Form

Information for Referrer:

North West Sussex - SPMHS - Referral Form

Referral Details:

Patient Demographics:

Professionals Involved:

Reason for Referral:

Terms & Conditions:

Crisis Information: