Children’s Health Queensland Hospital and Health Service Referral e-PIMH Telepsychiatry	(Affix patient identification label here)
Phone: 07 3266 0300 / Fax: 3266 0344 / Email: e-PIMH@health.qld.gov.au
Please note this is NOT a crisis service. Please call the relevant emergency services in your area for crisis support.
This secondary consultation service provides specialist advice for pregnant and postnatal parents (up to 24 months postpartum) and their infant/child (up to 5 years) who are experiencing mental health (social and/or emotional) issues. To assist in the process, please provide as much information as possible. Please note all named referrals are saved on the Queensland Health confidential mental health database (CIMHA).
Date of referral: Click or tap to enter a date.
Does the consumer agree to the referral being made to e-PIMH? Yes No Does the consumer agree to their information being provided below? Yes No If consumer is unable to consent, who is consenting? If no, please DO NOT include any identifying information. Video conference session Telephone consult (please note this is NOT a crisis intervention service)
Referrer Details (required)
Name:	Position:
Organisation:	Town:
Phone:	Email:
GP Details (required for referrals where consumer will be seen via telehealth)
Name:
Practice name:
Postal address: Postcode:
Phone:	Email:
Perinatal Consult (up to 24 months postnatal) *Do not complete these details for de-identified consultations
Consumer’s full name:
Date of birth: Click or tap to enter a date. Gender: Phone:
Address: Postcode:
Antenatal Postnatal
Gestation: Age in weeks and/or months: Breastfeeding: Yes No Mixed Feeding
Name of infant/child:
EPDS/KMMS Score: *If EPDS/KMMS is over 12, or positive for Q10, please consider a referral to the local adult mental health team.
Partner: Yes N/A Have you completed other relevant assessments (e.g. iCOPE)? Yes No If yes, please attach Other children (names and ages):
e-PIMH Peer Worker requested for consult: (please see attachment for more information)
Infant/Child Consult (under 5 years) *Do not complete these details for de-identified consultations
Consumer’s full name (infant/child):
Date of birth: Click or tap to enter a date. Gender: Phone:
Address: Postcode:
Age of infant/child in (years/months/weeks):
Parent/Carer 1 full name:
Parent/Carer 2 full name:
Siblings (names and ages):
Aboriginal and/or Torres Strait Islander, Cultural and Linguistically Diverse *Cultural considerations for referrer to discuss with consumer
Consumer / Parent / Carer 1 Cultural background:	Connection to culture:
Connection to cultural supports (please list):	Country of birth / year of arrival:
Parent / Carer 2 Cultural background:	Connection to culture:
Connection to cultural supports (please list):	Country of birth / year of arrival:
Infant / Child Cultural background:	Connection to culture:
Connection to cultural supports (please list):	Country of birth / year of arrival:
Interpreter required – languages:
Consults with Aboriginal and/or Torres Strait Islander families will be held with an Aboriginal and/or Torres Strait Islander team member. Please check “No” to decline: No
Cultural / Religious / Spiritual Considerations *See attachment
Connection to country, religion, proximity to culture/spirituality, connection to family/community, community expectations of the consumer, migration history, experience of racism/persecution.
Reason for Referrer seeking Secondary Consultation and Support
Review psychiatric assessment and diagnosis (excluding neurodevelopmental disorders) Perinatal medication review including use during pregnancy and breastfeeding Review treatment planning and recommendations for: Parent/Carer Infant/Child Review parent/infant relational assessment and intervention Consult re. additional resources and support: Lack of relevant local services Consult re. seeking cultural support for Parent/Carer or Infant/Child
Please detail current protective and risk factors for the consumer (please see attachment). Include cultural considerations, mental health concerns, changes to medication or referral to other mental health services, disabilities/neurodevelopmental/sensory concerns that should be considered for consult. Note: Please contact your local adult mental health team, emergency services or child and family services in your area if there are any concerns about immediate safety (including acute risks of self-harm, suicide, domestic and family violence, vulnerability and substance use).
Consumer Goals
Please ask consumer about their goals for e-PIMH consult
Medications (current and past – if more space is needed, please attach to back of form)
Medication	Date prescribed	Dose	Duration	Reason	Consumer feedback (e.g. effectiveness, side effects)
Observations of the Infant/Child and Parent Child Interactions *See attachment
Include sleeping or feeding, emotional states, child’s response to interactions.
Process of Referral for Secondary Consultation
Please send the completed form via email (e-PIMH@health.qld.gov.au) or fax (07 3266 0344) e-PIMH will confirm receipt of the referral Once required information is collected, e-PIMH will liaise with the Consultant Psychiatrist to confirm appropriate dates/times to videoconference together with referrer e-PIMH will confirm date/time and videoconference details If consumer attending consult, referrer is to confirm details with consumer directly e-PIMH will not usually contact the consumer Please note referral information is saved to Queensland Health confidential mental health database (CIMHA) Referrer is to organise and coordinate an interpreter if required NOTE: Responsibility for follow-up with the consumer remains with the referrer.
Please contact e-PIMH on (07) 3266 0300 if there are any questions or to discuss the referral further.

Aboriginal and/or Torres Strait Islander Consumer’s Considerations What is consumer’s language/clan group and/or community? Cultural heritage at forefront of all activities. Aboriginality (and Torres Strait Islander heritage) is a protective factor. Stop perpetuation of another Stolen Generation. What is consumer’s family story? Stolen Generation history indicates presence of transgenerational trauma. Intergenerational contact with Child Welfare and Youth Justice indicates presence of transgenerational trauma. Understand immediate family story of racism and social disadvantage. What is consumer’s connection to family? Connection to biological family can influence ways of connecting to culture. Connection to family = Connection to cultural heritage. Significant relationships to family highlights protective and risk factors. What is consumer’s proximity to culture? Close relationship to culture highlights a social and emotional connection to culture. Distant relationship highlights abstract connection to culture. Close relationship to culture highlights the systems understanding that culture is significant for development. Close connection to culture shows consumer was/is supported/allowed to safely build a connection to cultural heritage.	Culturally and Linguistically Diverse / Refugee / Asylum Seeker Consumer’s Considerations Note: Although consumer may be proficient in English, it can be challenging to discuss topics when highly ancious or emotional if English is not the consumer’s preferred language. Consider consumer’s primary language/birth country and/or community What is consumer’s explanatory story/understanding of their mental health? Ask questions in a way the consumer understands. Asking questions in different ways. Connection to community can be a protective factor. Explore consumer’s perspective. What is consumer’s migration/asylum-seeking story? History of persecution could indicate presence of transgenerational trauma. Understand immediate family story of racism and social disadvantage. Potential fear of government/people with perceived power. What is consumer’s connection to family? Do relatives reside overseas? Is there concern for their safety? Is there a sense of connection to cultural heritage? Significant relationships to family highlights protective and risk factors. What is the consumer’s role within the family (may be based on gnder and/or age and birth position). Are there continuing obligations to family? What is the consumer’s proximity to culture? Close relationsip to culture highlights a social and emotional connection to culture. Close relationship to culture highlights that systems understand the role of cultue in a child’s development. Importance of a strong identity and sense of self. Was the client supported/allowed to safely build a connection to cultural heritage? How much of the new culture have they integrated into their own cultural heritage?
Infant Observations Infant has sleep difficulties – sleeps too much, unable to settle to sleep, disrupted/unsettled sleep Infant has feeding problems – infant not putting on weight, vomiting, constipation/diarrhoea, poor sucking, etc Infant seems stressed or anxious – infant flinching / startles/ ‘jumpy’ / scared, freezes, overly friendly to strangers, restricted play or exploration of the environment, displays aimless motion, etc Infant is unsettled or irritable - inability to comfort, crying/whimpering, inconsolable crying, easily frustrated, excessively fussy, difficult to soothe/console, repeated nightmares Infant has aggressive behaviours - increased aggressive behaviours (hitting, biting of others) Infant has developmental delays - suspected delays, explain diagnosed delays Is there something about this infant that you feel is concerning but is difficult to describe?	Parent-Infant Relationship-Observations Infant is excessively fearful of being separated from caregiver, caregiver is overinvolved and/or intrusive Poor eye contact between caregiver and infant, infant appears very independent or indifferent to caregiver Caregiver perceives infant behaviour negatively Caregiver seems frightening to infant, caregiver seems frightened of infant, infant resistant to cuddling, presents with stiff/floppy body posture Infant scapegoated

Protective Factors Able to list strategies to keep well and/or safe Connected to spirituality or cultural beliefs Connectedness to social support/supportive family Access to cultural practices and sense of belonging Clear sense of self and identity Medical/health and wellbeing compliance Displays help seeking behaviours Financial security/housing stability Engaged with other services	Risk Factors Current or historical suicidal ideation/self-harm Thoughts of harm to others including infant Elevated EPDS/KMMS screen Previous diagnosed mental illness Isolation/lack of support Excessive alcohol and/or drug use Financial difficulties Family history of mental illness Has been exposed to domestic and/or family violence Loss or grief Experience of trauma (intergenerational, birth trauma, etc) Other medical problems/chronic health concerns Misunderstanding/disagreement of diagnosis
e-PIMH Peer Worker What is an e-PIMH Peer Worker? An e-PIMH Peer Worker is a person who has a Lived or Living Experience of perinatal mental ill health, and of parenting infants and young children who are struggling with their social and emotional wellbeing. Peer Workers are not clinical professionals, and instead, use their experiences to support families, parents and caregivers throughout the e-PIMH process. Is there always a Peer Worker available? While we strive to make this service available for all consults if requested, there may be times where there is no Peer Worker available. In this instance, we will put you in contact with other telephone or online peer support options, like PANDA, or offer a pre-consult and/or follow up phone call from one of our Peer Workers. What will the Peer Worker do? Once you have confirmed you would like a Peer Worker present, and we have confirmed that there is availability, our Peer Worker will offer to contact you before the consult to prepare you for what it will look like. They can also discuss ways you can both communicate during the consult to ensure you feel safe throughout the session. During the consult, the Peer Worker will be there to support you, offer insights from their own lived experiences, and help you to communicate your needs and concerns.