Self Referal – Perinatal Mental Health Borders

Self Referral

You can self-refer to PMH Borders by completing this referral form with your contact details, family information, healthcare provider details, and a brief outline of the difficulties you are experiencing.

The information you provide helps us understand your current situation, any support or treatment you are already receiving, and how we may be able to help.

Once submitted, your referral will be reviewed by the PMH Borders team, who will contact you about the next steps.

PMH Borders Referral Form

Please complete the details below and the PMH Borders team will contact you about next steps.

1 Your Details

2 Family

3 Healthcare

4 Referral

Your Details

Name *

Preferred Pronouns *

Date of Birth *

Address *

Postcode *

Phone Number *

Email Address *

Have you previously received a service from PMH Borders? *

Yes No

If yes, approximate date

Family Profile

Add each child using the name and date of birth fields below.

Child 1 Name

Child 1 Date of Birth

Name of Partner

Partner's Date of Birth

Relationship Status

Next of Kin Name *

Next of Kin Phone Number *

Healthcare Provider

Please advise who would hold overall medical responsibility if symptoms increase or were of major concern.

Healthcare Provider Name *

Position

Healthcare Provider Address *

Healthcare Provider Postcode

Healthcare Provider Phone Number *

Name, address and contact number of any other agencies or healthcare professionals involved

Reasons for Referral

Brief outline of difficulties you are experiencing *

Relevant past medical, psychiatric or family history *

Current supports / treatment, including all medication

Significant information about your children or family

Trainee Counsellors

We occasionally have Trainee Counsellors working with us. All Trainees are carefully selected to ensure they are at an appropriate level in their training to work with our families and are provided with a high level of supervision and support. Sessions with a Trainee Counsellor are offered at a reduced rate.

Please tick this box if you are happy to work with a Trainee Counsellor.

Please indicate your donation preference *

Pay what you can - make a contribution based on household income / affordability Fixed Amount - pay £60 per session via direct debit Pay it forward - pay £75 per session, with a proportion supporting someone unable to access the service

I consent to PMH Borders receiving and processing the information submitted in this referral form. *

Date *

info@pmhborders.org.uk

East Lodge, Elm Row, Galashiels, TD1 3HT

01896 751 609

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