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**
Referrer Details
Referrer Organisation
Street Address
Suburb
State
Please select...
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
First Name
Last Name
Position
Please select...
Counsellor
Early Childhood Professional
GP
Maternal and Child Health Nurse
Midwife
Occupational Therapist
Other
Psychiatrist
Psychologist
Social Worker
Student
Job Title
Phone
Fax Number
Email
Client Details
First Name
Last Name
Date of Birth __/__/____
Gender
Male
Female
Other
Street Address
Suburb
State
Please select...
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Phone Number
Email (Where possible, please provide)
Consent for PANDA to leave a message?
Yes
No
Aboriginal or Torres Strait Islander?
Yes
No
Language spoken at home:
Interpreter Needed?
Yes
No
Born in Australia
Yes
No
Where were they born?
Has the client ever received specialist mental health care?
Yes
No
Please provide details:
Perinatal Status
Perinatal Status
Antenatal
Postnatal
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:
Diagnosis (if any)
Perinatal Depression
Perinatal Anxiety
Bipolar Disorder
Obsessive Compulsive Disorder
Borderline Personality Disorder
Eating Disorder
Other
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)
Risk Assessment
Suicide
Yes
No
Unknown
Self Harm
Yes
No
Unknown
Alcohol and Drug Use
Yes
No
Unknown
Family Violence
Yes
No
Unknown
Please Specify
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
Need assistance with this form?
