Young person referral form – Essex Sexual Health Service

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Young person referral form

The One-to-One Education and Early Intervention Programme is currently at capacity therefore we are unable to accept new referrals at present.

We anticipate the programme will re-open for new referrals in October and we will update the website accordingly.

If you would like to speak to someone within the team, please contact provide.essexyoungpeople@nhs.net

Italian Trulli

Has the young person consented to the referral being made? *

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We are Sorry

We cannot accept a referral unless the young person has consented to the referral

Young person's name *

Date of Birth *

Gender *

Ethnicity *If known, please state the ethnicity of the young person

Postcode of home/main residence *

Client/young person’s contact details if known’

Contact details for parent/guardian, if aware of referral

School or college attended *Please write 'none' if the young person is not in education.

Have you discussed this referral with the young person? *

Have you explained your concerns to the young person? *

Identity

This young person…has in the past been a looked after childis currently a looked after childis known to social care/CFP teamshas a diagnosed or suspected special educational need or requirementhas had involvement with the police in the last two yearsis currently working with another support/intervention servicePlease tick all that apply.

If you ticked any of the above, please record details below.

If they are known to social care, please provide name and contact details for their social worker.

Has this referral been discussed or referred into the children’s and family hub? *If yes, please give further details below.

More details *

Disclosures

Has the young person disclosed any of the following:They are currently sexually activeThey are having non-consensual sexWants to become pregnantHas had an unplanned pregnancyThey are paying for/being paid for sexThey do not feel safe, please record details below

Please provide further details *

Has the young person disclosed they have had: *Penetrative sex (vaginal and/or anal sex)Oral SexMutual masturbation(please tick all that applies)

Has the young person disclosed that they have experienced any of the following *Non-consensual penetrative sex (vaginal and/or anal sex)Non-consensual oral SexNon-consensual mutual masturbation(please tick all that applies)

Has sent or received sexual imagery online/electronicallyDisplaying sexualised/inappropriate behaviour

Age of current partner (if applicable and known)

Number of sexual partners they have had (if known)

Relationships

Do you have any evidence of grooming in their current or past relationships? *If you answered yes above, please state whether they were victim or perpetrator.

More details *

Do you have any evidence of sexual exploitation in their current or past relationships? *If you answered yes above, please state whether they were victim or perpetrator.

More details *

Do they have supportive relationships with adults? *Please give further details below.

More details *

Home life

Are there concerns regarding drug and/or alcohol use? *If you answered yes above, please give further details below.

More details *

Have they experienced or witnessed domestic violence? *If you answered yes above, please give further details below.

More details *

Has this person ever gone missing? *

More details *

Reasons for referral

Please state your specific concerns and reasons for referral *

Referrals will only be considered if the reasons for referral meet the criteria for the 1:1 programme.
Please provide us with as much information as it is appropriate or relevant to share. Any details of current or historic social care or police involvement must be disclosed if not detailed elsewhere.
Please note lack of information or explanation regarding key concerns may result in a referral being declined due to lack of information.
The 1:1 programme is an education intervention and is not counselling. If the client/young person requires mental health support we would recommend an alternative referral to a counselling service.
Please provide us with as much information as it is appropriate or relevant to share. Any details of current or historic social care or police involvement must be disclosed if not detailed elsewhere.

Please tick the interventions or topics you feel would be most relevant (up to 3). *Healthy relationshipsConsentOnline safetySexting/online sexual materialSexual health - STIsSexual health – contraception/pregnancyPuberty/developmentSex and the lawSelf-esteem/confidence and assertivenessLGBTQ+ specific sexual healthPlease tick up to 3

For schools

Please only fill in this section if the young person is being referred from a school setting. If not, please skip to the Referrer Information section below.

Name of school or academyContact details for named professional within school (if different to referrer)

Do they engage well with professionals?

Will you be able to provide a confidential setting for us to conduct sessions?

Referrer information

Referrer Name *

Referrer Job title *

Referrer Organisation *

Referrer Contact number *

Referrer Contact email *

Please type your name below to sign that you confirm this referral *Countersigned by young person to give consent for referral. This can also be a verbal agreement.

Location

Your proposed location for 1:1 sessions to take place

Is there any further information you feel it would be helpful for us to know?For example, regarding availability or engagement.

Safeguarding lead

Please fill this in with your own details if you are the organisational safeguarding lead.

Please tick to confirm that it has also been shared with the organisational safeguarding lead.

Essex Sexual Health service reserves the right to decline any referrals that do not meet our criteria, or that we feel would be more appropriate to another service.
We endeavour to respond to new referrals within 10 working days, but under specific circumstances this may take longer
We do not work with young people currently receiving support from another service, or who are the subject of a current, open police investigation.

For any queries or concerns regarding making a referral, please contact provide.essexyoungpeople@nhs.net.

Please do not submit a referral below until you have read the

Essex 1:1 education programme’s criteria

(this will open a PDF in a new window).

Essex Sexual Health Service is delivered by:

Contact Us

0300 003 1212

Your journey with Essex Sexual Health Service begins with a conversation. Whatever your query or area of interest, we’re here to help. From detailed enquiries about our diverse services to general information requests, our dedicated team is ready to assist you.

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