Sexual Health St Helens

Date of referral*:

Name of referrer*

Organisation*:

Designation*:

E-mail address*:

Contact Number:

Young Person Details

Please indicate that consent has been sought and agreed from the young person and their parent/carer. Please note that parental knowledge is not always required to make a referral, but referrals cannot be accepted without the young person’s consent.

Young person's consent given: YesNo

Name*:

Preferred Name*:

Date of Birth:

Gender at birth:

Is their gender the same today? YesNo

Address*:

Postcode:

Mobile Number:

Other contact details:

Preferred method of contact:

Language:

Education provision*:

Year Group:

Disability or SEND*:

GP name and Surgery*:

Parent/Carer Details

Parent 1 consent given*: YesNo

Parent 1 Name:

Address:

Number:

Parent 2 consent given: YesNo

Parent 2 Name:

Address:

Contact Number:

Level of need*

Support already in place

Name:

Organisation:

Role:

Reason for involvement:

Name:

Organisation:

Role:

Reason for involvement:

Young person and parent/Carer consent given for TAZ Outreach Team contacting the above services for additional information if required?*: YesNo

What is working well for this young person?

Support from parent/Carer/FamilyGood friendshipSchool AttendanceInterests outside of schoolAcademic attainmentSomething else (detail below)

Risk Indicator Tool:

How would you rate the concerns today?

Reason for referral and supporting information:

Explain the reason for your referral and what your expectations are, please give as much information as possible to support your referral*:

Support requested*

Contraception Contraception ChoicesSupport to access clinics

Pregnancy Pregnancy OptionsTermination of Pregnancy

Safer Sex STI informationSTI Screening

LGBT+ Information about being LGBT e.g. coming out/questioning/issues with gender identityReferral to Over the Rainbow (LGBT group)

Relationships Healthy RelationshipsConsentSelf esteem

Notes to referrer:

Each referral will be discussed at a screening meeting within 7 days. You will be contact if your referral is accepted, rejected or if more information is requested. If your referral is accepted, the case will be allocated to TAZ worker who will in contact with the young person on the method provided above.

13 to 18 years old
St Helens Resident
St Helens LAC
At risk of pregnancy
At risk of poor sexual health
At risk of sexual exploitation
Low level HSB with prior assessment

Under 13
Over 18
Non-St Helens Resident
High level of SEND
Require counselling including for sexual assault
High level of HSB
Low level of HSB without prior assessment

Data Privacy Notice:

The information provided on this form will be used in accordance with the General Data Protection Regulations, 2018. Your information will be utilized for the purposes of providing you with services as requested above. Your details will not be shared with any other services without you consent.

TAZ Referrals

Referrer Details