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
Please list up to three other professionals involved with the young person below. If there are any more, please email the details to
If you wish to talk to the outreach team prior to sending this referral form please call 01202 858372 (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