PANDA - National Perinatal Mental Health Helpline Referral Form

Completion of this form requires this referral to be discussed with the client and informed consent confirmed. This includes contact details so PANDA can contact the client. Please provide as much information as possible to support triage to PANDAs services.

PANDA takes caller privacy seriously, please click here to view our Privacy Policy. For privacy reasons, we may contact you via phone to advise on the status of the referral. We are not able to send identifying information about your client via email.

PANDA works with families throughout pregnancy and until the child is 12 months old. For parents of older children, please contact Parentline in your state (see table below for phone numbers and open hours), or the Pregnancy Birth Baby Helpline on 1800 882 436.

Parentline
State	Telephone	Hours
ACT	02 6287 3833	9am – 4pm Mon-Fri
QLD	1300 30 1300	8am – 10pm, 7 days
NT	1300 30 1300	8am – 10pm, 7 days
NSW	1300 130 052	9am – 9pm Mon-Fri, 4pm – 9pm Sat-Sun
SA	1300 733 606	7:15 am – 9:15 pm, 7 days
TAS	1300 808 178	24 hours, 7 days
VIC	13 22 89	8 am-midnight, 7 days
WA	1800 111 546	8 am – 8 pm, 7 days

If you require a copy of the referral for your records please ensure you print or save a copy as a PDF.

Perinatal Status

The following information supports us in directing your referral to the right PANDA Helpline service.

Perinatal status

Antenatal (during pregnancy)Postnatal (first 12 months after birth)

Estimated delivery date:

Weeks postpartum:

D.O.B

(dd/mm/yyyy)

Infant's first name:

Infant's last name

Names and DOB of other children (If any)

GP Name and practice (if this referral is not coming from a GP)

Other health professionals/services currently involved:

Please specify

Screening tool used

Screening score

Screening date

(dd/mm/yyyy)

Please upload any relevant screening tools (K10, EPDS) and treatment plan

Current medications

Past medications

Current symptoms

Current supports

Mental health history

Reason for referral

Other referrals made

(e.g acute mental health triage, helplines, counselling, family services, medical)