ࡱ>  bjbj11 D[g[g3 00444HHH8,Hb& ,pf-f-f-B4<\t@0```````$d[gX`e4BN3N3BB`00f-f-9b,I,I,IBR0f-0f-`,IB`,I,IZJ\f-3,B~[`Ob0b[gCg(\\\g4\BB,IBBBBB``jFBBBbBBBBgBBBBBBBBB X :  Gold Coast Health LAVENDER MOTHER AND BABY UNIT REFERRAL Facility:  FORMTEXT        (Affix identification label here) URN:  FORMTEXT       Family name:  FORMTEXT       Given name(s):  FORMTEXT       Address:  FORMTEXT       Date of birth:  FORMTEXT       Sex:  FORMCHECKBOX  M  FORMCHECKBOX  F  FORMCHECKBOX  IReferrer Details Date of Referral:  FORMTEXT      Time of Referral:  FORMTEXT      Name:  FORMTEXT      Designation:  FORMTEXT      Referral Agency:  FORMTEXT      Contact Person:  FORMTEXT       (If not referrer)Address:  FORMTEXT      Telephone:  FORMTEXT      Mobile:  FORMTEXT      Fax:  FORMTEXT      Email:  FORMTEXT      Hospital Health Service:  FORMTEXT      If not from Gold Coast Health, please complete  HYPERLINK "https://www.qld.gov.au/__data/assets/pdf_file/0023/56255/form-b-travel-refer-inter-20190214.pdf" Travel Subsidy Scheme documents. Consumers nearest hospital must be greater than 50kms away from GCUH to be eligible.Mother s DetailsGiven Name(s):  FORMTEXT      Family Name:  FORMTEXT      Date of Birth:  FORMTEXT      Email:  FORMTEXT      Address:  FORMTEXT      Phone number(s):  FORMTEXT      Homeless / At risk of homelessness? FORMCHECKBOX  Yes  FORMCHECKBOX  NoCountry of Birth:  FORMTEXT      Preferred Language:  FORMCHECKBOX  English FORMCHECKBOX  Other:  FORMTEXT      Year of arrival:  FORMTEXT       FORMCHECKBOX  N/AInterpreter required? FORMCHECKBOX  Yes  FORMCHECKBOX  NoAboriginal or Torres Strait Islander Status: FORMCHECKBOX  Aboriginal FORMCHECKBOX  Torres Strait Islander FORMCHECKBOX  Not stated / Unknown   FORMCHECKBOX  Neither FORMCHECKBOX  BothIs the mother a current inpatient? FORMCHECKBOX  Yes  FORMCHECKBOX  NoPrivate Health Insurance with hospital admission cover? FORMCHECKBOX  Yes  FORMCHECKBOX  NoMHA Status: FORMCHECKBOX  Voluntary  FORMCHECKBOX  Involuntary Is client aware of referral: FORMCHECKBOX  Yes  FORMCHECKBOX  NoIs client accepting of referral? FORMCHECKBOX  Yes  FORMCHECKBOX  NoBabys DetailsFirst Name:  FORMTEXT      Last Name:  FORMTEXT      Date of Birth:  FORMTEXT      Gender:  FORMTEXT      Immunisation Status:  FORMTEXT      Country of Birth:  FORMTEXT      Mode of feeding: FORMCHECKBOX  Breast  FORMCHECKBOX  Formula  FORMCHECKBOX  Solids  FORMCHECKBOX  Weaning Is mother the primary carer?  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  UnknownWho has parental responsibility? FORMCHECKBOX  Father FORMCHECKBOX  Mother FORMCHECKBOX  Other:  FORMTEXT      Father of baby first name:  FORMTEXT      Father of baby last name:  FORMTEXT      Is father of the baby involved in care? FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  UnknownAddress of father of baby (if different to mother s):  FORMTEXT      Mobile:  FORMTEXT      Email:  FORMTEXT      Is father of baby consenting to admission of infant? FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  N/AAny concerns regarding baby s physical health? (If yes, please state below) FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Any concerns regarding baby s mental health? (If yes, please state below) FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Infectious Disease StatusBaby is free of infectious disease for >48 hours? FORMCHECKBOX  Yes  FORMCHECKBOX  NoMother is free of infectious disease for >48 hours? FORMCHECKBOX  Yes  FORMCHECKBOX  NoFamily CompositionCurrent partners first name:  FORMTEXT       (If different to father of baby)Current partner s last name:  FORMTEXT       Address (If different to mother s):  FORMTEXT      Mobile:  FORMTEXT      Email:  FORMTEXT      Other ChildrenFirst NameLast NameAge / DOBGenderWho has parental responsibility?Who will be the caregiver during admission? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Please state name and contact details for who else is actively involved in the children / family s care: (e.g. family / friends)  FORMTEXT      Please state name and contact details of others who live in the same house:  FORMTEXT      Referral DetailsReason for Referral (Include referrer s rationale for inpatient treatment, onset, duration, triggers, mental state and current social circumstances)  FORMTEXT      Physical health problems / Comorbidities (including birth-related and postpartum)? (e.g. thyroid problems, anaemia / low iron, hypertension, pain, gestational diabetes and sepsis) FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unknown FORMTEXT      Current  Amount / FrequencyPastNicotine FORMTEXT       FORMTEXT      Alcohol use FORMTEXT       FORMTEXT      Other substances (please list) FORMTEXT       FORMTEXT      Relevant past mental health history:  FORMTEXT      Concerns with Parent-Child relationship FORMCHECKBOX  Problems bonding with baby  FORMCHECKBOX  Lacks confidence with practical baby s cares  FORMCHECKBOX  feeding  FORMCHECKBOX  sleeping  FORMCHECKBOX  settling  FORMCHECKBOX  nappy changes  FORMCHECKBOX  bathing  FORMCHECKBOX  identifying baby s cues FORMCHECKBOX  Other:  FORMTEXT      Strengths and protective factors (Insight, good social support, resilience)  FORMTEXT      Current Medication  FORMTEXT      Risk factors (Adult Mental Health Services complete a CIMHA risk assessment)  FORMCHECKBOX  Completed  Date:  FORMTEXT       FORMCHECKBOX  At risk of harm to self:  FORMTEXT       FORMCHECKBOX  At risk of harm to baby:  FORMTEXT       FORMCHECKBOX  Criminal offences:  FORMTEXT       FORMCHECKBOX  At risk of harm to others:  FORMTEXT      Please outline your intended care plan until admission (If accepted for admission)  FORMTEXT      Custody arrangements: FORMCHECKBOX  Formal FORMCHECKBOX  Informal FORMCHECKBOX  No FORMCHECKBOX  UnknownDomestic Violence Orders: FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownProfessional NetworksGeneral PractitionerGP Name:  FORMTEXT      Telephone:  FORMTEXT      GP Clinic:  FORMTEXT      Mobile:  FORMTEXT      Address:  FORMTEXT      Fax:  FORMTEXT      Email:  FORMTEXT      Mental Health ServiceAdult Mental Health Service involved with the family? 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FORMTEXT       FORMCHECKBOX  Advance Health Directive FORMCHECKBOX  Nominated support person  Name:  FORMTEXT      Other Services  Current or Planned post-dischargeServiceNameContact details FORMCHECKBOX  Private Psychiatrist FORMTEXT       FORMTEXT       FORMCHECKBOX  Child Health FORMTEXT       FORMTEXT       FORMCHECKBOX  NDIS FORMTEXT       FORMTEXT       FORMCHECKBOX  Family Support Services FORMTEXT       FORMTEXT       FORMCHECKBOX  Private Psychologist FORMTEXT       FORMTEXT       FORMCHECKBOX  Other:  FORMTEXT       FORMTEXT       FORMTEXT      Child SafetyCurrent child protection concerns? (If yes, please specify below) FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  Unknown FORMTEXT      Any child protection notifications been made? FORMCHECKBOX  Yes  Date:  FORMTEXT       FORMCHECKBOX  No FORMCHECKBOX  UnknownPrevious involvement with Child Safety Services? FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  UnknownPlease state nature of involvement below:  FORMTEXT      Child Protection Orders: FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  UnknownDetails:  FORMTEXT      Name of Child Safety Office:  FORMTEXT      Address:  FORMTEXT      Telephone:  FORMTEXT      Email:  FORMTEXT      Referrer Name:  FORMTEXT      Designation:  FORMTEXT      Signature: Date:  FORMTEXT       Referral Information Who can refer to Lavender Mother and Baby Unit We will accept referrals from Medical Practitioners General Practitioners Psychiatrists Obstetricians Paediatricians Mental Health Services It is expected that General Practitioners, Obstetricians and Paediatricians will have actively discussed with their Mental Health Service escalating the level of local mental health support and intervention to the mother before referral to the Lavender Mother and Baby Unit. Eligibility criteria for referral: Woman will or be expected to require mental health inpatient treatment as their mental health needs cannot be met by community care or there are significant risks to safety of the woman or her infant requiring inpatient management Have diagnosis of severe mental health problems: severe depression severe anxiety schizophrenia psychosis including postpartum psychosis bipolar affective disorder Be the primary carer of the baby / babies who are not walking and under 12 months Women with a substance or alcohol use disorder will only be considered for admission following detox and completion of withdrawal treatment Medical clearance that mother and infant are no longer contagious ( HYPERLINK "https://www.health.qld.gov.au/__data/assets/pdf_file/0022/426820/timeout_poster.pdf" as per latest guidelines) from any infectious disease Must reside in Queensland and not be homeless or at risk of homelessness Lavender Mother and Baby Unit will not admit women for the sole purpose of assessment of parenting capacity Referral Process Assessment of mother for severe mental health problem and determination she meets above eligibility criteria. Telephone Lavender Mother Baby Unit Intake on (07) 5687 7064 to discuss the referral between 0800  1600 Monday to Friday Complete attached referral form and fax to (07) 5687 7814 or email to GCUH_Lavender@health.qld.gov.au Referrals will be discussed, and the referrer will be notified of the outcome within two (2) working days If the referral is deemed suitable for admission a pre-admission assessment for suitability may be arranged either face to face or via skype with the patient and referrer The baby will require a pre-admission health screen to ensure that the baby is well. This to be completed by the baby s General Practitioner, or the local HSS Child Health Nurse, Paediatrician. There is no capacity to admit ill infants Referrals are prioritised according to the following criteria Acuity Babies under 6 weeks will be prioritised Breastfeeding status Availability of alternate outpatient management To ensure your referral is appropriately prioritised please provide weekly updates or more frequent if required, particularly if the woman s clinical presentation changes When a bed becomes available the referrer and patient will be contacted The local HSS to arrange transport of the patient and the baby Lavender Mother and Baby Unit admissions are planned and will occur Monday to Friday 0800  1600hrsIf there is a delay prior to admission, the Lavender Mother and Baby Unit can take no responsibility for management or support of the patient. The referring professional or service hold the responsibility and governance of the woman and baby s care and management until they are admitted to the Lavender Mother and Baby Unit. Alternative supports from the following services can be recommended Support Services Women, children and fathers need ongoing support if there is a wait time prior to admission. 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