Check it Out Outreach Service Referral Form Referral checklist Note: Questions marked by * are mandatory Please do not hesitate to contact the team at: esth.rosehill-clinic-cio@nhs.net, to discuss a young person’s needs prior to referral or if you feel they may benefit from targeted support but may not fit within the commissioned age range. Young people should not be referred to sexual health if they do not want support. Email us to discuss other options. Please tick each statement to confirm you understand the eligibility requirements for The Targeted Outreach Service. I confirm the young person is aged between 13-19 years old / is between 13-24 years old and has a SEND vulnerability I confirm I have directly spoken with the young person and they agree and understand and that they are open/ready to make changes to actively want to improve their sexual health with support from their CIO practitioner Willing to meet with their CIO practitioner for follow up appointments if necessary Agree to engage with their CIO practitioner to set goals regarding improving their sexual health and actively work with them to achieve these goals They understand that this is a voluntary service and they do not have to engage with their CIO practitioner, if multiple creative attempts are made to engage them fail, then their case will be closed. That they understand that the information shared with their CIO practitioner is confidential however maybe shared following discussion if they disclose information that describes potential risk to their or another person's safety or of a criminal nature You are here: Page 1 of 3
