PANDA - Perinatal Anxiety & Depression Helpline Referral Form

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

**All referrals will be triaged, please provide as much information as possible**

PANDA works with families throughout pregnancy and until the child is 12 months old

Referrer Details

Referrer Organisation

Street Address

Suburb

State

Postcode

First Name

Last Name

Position

Job Title

Phone

Fax Number

Email

Perinatal Status

AntenatalPostnatal

Estimated Delivery Date:

Weeks Postpartum:

D.O.B __/__/____

Infant's First Name:

Infant's Surname

Names and DOB of other children (If any)

GP Name and Practice

Other health professionals/services currently involved:

Please Specify

Screening Tool Used

Screening Score

Date __/__/____

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)

Record of Client Consent

The client agrees that the above information may be shared with PANDA in order for them to contact me and offer support. Please tick below to confirm:

Verbal consent to contact confirmed

I the referrer have discussed the referral with the client and am satisfied that they understand the proposed uses and disclosures and have provided their informed consent to these. Please tick below to confirm:

Referral discussed with client and informed consent confirmed