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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. 

PANDA takes caller privacy seriously, please click here to view our Privacy Policy. 

Please provide as much information as possible to support triage to PANDAs services. 

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 or the Pregnancy Birth Baby Helpline 1800 882 436. 

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











Client Details
















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





















Risk Assessment
PANDA aims to provide targeted support to at-risk callers. Where known, please include the following information relating to the client's current experience of:







Record of Client Consent