Targeted Outreach Service - Referral Form

Eligibility check list

Please tick each box to confirm you understand the eligibility requirements for The Targeted Outreach Service.

I confirm the young person is aged between 11-19 years old (year 7 and above) or is between 13-24 years old and has an additional vulnerability such as learning disability and lives in Dorset or attends school/college in Dorset *
I confirm that I have directly spoken to the young person and we have viewed the information regarding targeted outreach support on *
I confirm I have directly spoken with the young person and they agree and understand:
that they are ready to make changes to actively want to improve their sexual health with support from their sexual health advisor *
to meet with their advisor for up to 6 sessions *
to engage with their advisor to set goals regarding improving their sexual health and actively work with them to achieve these goals *
that they understand that this is a voluntary service and if they do not engage with their advisor their case will be closed. Young people should not be referred to sexual health if they do not feel they need support *
that the information shared with their advisor is confidential however maybe shared following discussion if they share information that describes potential risk to theirs or another person's safety or of a criminal nature *

Young Person's Details

Gender *
Preferred contact method *
Can messages be left by text/voice or both? *

Referrer's details

Additional vulnerabilities - Please tick below all that apply

You will receive acknowledgement of the referral within 2 working days.

The referral will be assessed based on the information given. Confirmation of whether the referral has been accepted or declined will be emailed to you within 5 working days. If inappropriate for outreach we will endeavour to signpost to a more relevant service if possible.

Please email or call 01202 858372 if you wish to discuss a referral

Sexual Health Dorset