Referral for support – OLD – Perinatal Wellbeing Canterbury

Our support is non-clinical and designed for parents with a mild to moderate decline in mental wellbeing. We are not a crisis service and do not have after hours or weekend services.

For urgent or crisis mental health care call 111
or the Crisis Resolution Service on freephone 0800 920 092

We aim to contact all our referrals within 3 business days. Self-referrals are welcome.

"*" indicates required fields

Hidden

Referral Date

Referred client details

Name*

First Last

Date of birth*

If DOB is unknown please enter today’s date.

Gender*

Ethnicity*

Other – Ethnicity

Iwi

Enter up to 3

Address

Street Address Suburb City Post Code

Contact Phone*

Primary support person

First Last

Relationship to client

Primary support phone

Currently pregnant?*

Children

Please enter all children and their DOBs or due date if pregnant.

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Has there been previous perinatal mental illness?*

Previous mental health history*

Select all that apply

No previous history

Depression

Anxiety

Panic attacks

PTSD

Bipolar disorder

Psychotic episode

Eating disorder

Other

Reason for referral*

Supports in place

Main family support*

Partner's family support*

Mothers and Babies Service*

Is there recent involvement with the Maternal Mental Health services?

Date

Date referred to service or recent discharge date

Plunket – PNAP Service*

Is there recent involvement with the Plunket Postnatal Adjustment Programme service?

Date

Date referred to service or recent discharge date

Other service

Are there any other services involved for support? e.g. Early Start, OT, Barnardos, Te Puawaitanga

Date

Date referred to service or recent discharge date

Other service name

Please give the names of any other services involved.

Referrers details

Has there been consent for this referral?*

Name*

First Last

Phone

Email*

Referred by*

Referrer organisation

The name of the referral organisation.

CAPTCHA

Referral for support – OLD

Our support is non-clinical and designed for parents with a mild to moderate decline in mental wellbeing. We are not a crisis service and do not have after hours or weekend services.

For urgent or crisis mental health care call 111 or the Crisis Resolution Service on freephone 0800 920 092

Referred client details

Supports in place

Referrers details

Contact Us for Support

For urgent or crisis mental health care call 111
or the Crisis Resolution Service on freephone 0800 920 092