Targeted Outreach Service - Referral Form

Referral Details
Gender *
Preferred contact method *
Can messages be left by text/voice or both? *
Consent to referral (please note the young person will not be contacted until the adviser has had the opportunity to speak with the referrer) *
Please mark what concerns you have related to the young person
If you do not receive email communication that we have received your referral within 48 hours, please email dhc.sexualhealth.promotion@nhs.net
Captcha Code

If you wish to talk to the outreach team prior to sending this referral form please call 01202 729219 (ask for the outreach team)

Following this referral submission an assessment will take place based on the information given. If inappropriate for outreach we will signpost to relevant service for their need, you will be informed of this decision.


Sexual Health