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Maternal Behavioral Health Referral Form ****Please complete front of form and fax/email to provider selected on the back of the form**** For information on the RPN Perinatal Depression Project or

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How to fill out maternal behavioral health referral

01

Step 1: Obtain the maternal behavioral health referral form

02

Step 2: Fill out the patient information section completely, including name, age, contact information, and any relevant medical history

03

Step 3: Provide details about the referring provider, including name, contact information, and affiliation

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Step 4: Indicate the reason for the referral, specifying any specific behavioral health concerns or symptoms

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Step 5: Include any supporting documentation or medical records that may be relevant to the referral

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Step 6: Sign and date the referral form

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Step 7: Submit the completed referral form to the designated recipient or department

Who needs maternal behavioral health referral?

01

Pregnant individuals who are experiencing or at risk of developing behavioral health issues during or after pregnancy

02

Individuals with a history of mental health disorders who are pregnant or planning to get pregnant

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Pregnant individuals who have been identified by healthcare providers as needing specialized behavioral health support

04

Pregnant individuals who have experienced traumatic events or significant life stressors during pregnancy

05

Individuals with a family history of behavioral health disorders who are pregnant or planning to become pregnant

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What is maternal behavioral health referral?

Maternal behavioral health referral is a process by which pregnant women or new mothers are referred to mental health services for evaluation and treatment of any mental health concerns.

Who is required to file maternal behavioral health referral?

Healthcare providers, social workers, or any caregiver of pregnant women or new mothers may be required to file maternal behavioral health referral if they suspect there is a need for mental health evaluation and treatment.

How to fill out maternal behavioral health referral?

Maternal behavioral health referral can be filled out by providing the necessary information about the pregnant woman or new mother, their mental health concerns, and any relevant medical history. It is important to be thorough and accurate in the information provided.

What is the purpose of maternal behavioral health referral?

The purpose of maternal behavioral health referral is to ensure that pregnant women and new mothers receive timely and appropriate mental health support and treatment to promote the well-being of both mother and child.

What information must be reported on maternal behavioral health referral?

Information such as the name of the pregnant woman or new mother, their mental health concerns, any relevant medical history, and the reason for referral must be reported on maternal behavioral health referral.

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