Smart Phrase: Perinatal TiPS Referral
General Information
Referring physician:
Call back number:
Preferred call back time:
Did you get consent from your patient before calling Perinatal TiPS?
:
Yes
No
Presenting problem:
Pregnant or Postpartum:
How many weeks pregnant:
When was date of delivery (if postpartum):
Delivery outcome:
C-section
Vaginal
Preterm labor
Delivery
NICU admission
Any complications
Pregnancy outcome:
Fetal complications:
Is patient breastfeeding?
Yes
No
Any fetal complications?
Yes
No
Does this patient have a primary care provider?
Yes
No
Primary care provider name:
Psychiatric history:
Prior diagnosis:
Current medications:
Current treatment:
Recent psychiatric hospitalizations:
Yes
No
Prior suicide attempts or self-injury:
Yes
No
SUD history:
Any active substance use
:
Yes
No
Currently engaged in any SUD treatment:
Yes
No
Currently on any medications for SUD:
Yes
No
This is not a crisis referral pool. If you feel your patient is not safe, please follow your crisis protocols.
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Contact Information