Sexual Health Outreach - Make a referral

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Worcestershire Integrated Sexual Health Service
Sexual Health - Outreach
Sexual Health Outreach - Make a referral

Outreach - Professional referrals

Referral criteria

The service aims to improve access to nurse-led level 1 and 2 sexual-health care. The service will be offered to high-risk and vulnerable populations as well as those that are not able to access services due to learning, mental and physical disabilities. Services should be provided where clinically appropriate, and suitable alternative provisions made otherwise.

The below form is for use by professionals only.

Essential Information

Note: Questions marked by * are mandatory

Title

*This is a mandatory field. First name

*This is a mandatory field. Last name

Previous last name

*This is a mandatory field. Date of birth

Age

*This is a mandatory field. Gender

Ethnicity

Nationality

Country of origin

Language spoken if not english

Is an interpreter required?

*This is a mandatory field. Address

GP address

*This is a mandatory field. Does the patient have a disability

What kind of disability do they have

*This is a mandatory field. Does the patient have any communication needs?

Advocate
Audio
Braille
British Sign Language
Easy Read
Email
Hearing loop
Interpreter
Large print
Lip reading
SMS text
Telephone
Other
N/A

If other please specify

Patients phone number

Patient email address

Is the patient in education?

Name of school or college

Does the patient have children

*This is a mandatory field. Has the patient had a home visit in the past

*This is a mandatory field. Were there any safeguarding concerns

Description of safeguarding concerns

Do you have any lone working concerns with this patient

Detail of lone working concerns

*This is a mandatory field. Is there any history of domestic violence in the home

Detail of domestic violence

Are there any other professionals involved. Please provide name/job role/contact detail

Social worker name

Social worker email

Social worker telephone number

*This is a mandatory field. Reason for referral

*This is a mandatory field. Referrers name

*This is a mandatory field. Referrers email address

*This is a mandatory field. Referrers contact number

*This is a mandatory field. Referrers job role

*This is a mandatory field. Is the patient aware that you are making this referral?

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Worcestershire Integrated Sexual Health Service

Head Office

Herefordshire and Worcestershire Health and Care NHS Trust
2 Kings Court
Charles Hastings Way
Worcester
Worcestershire
WR5 1JR

T: 01905 760000

Our Partners

Herefordshire Council

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Worcestershire County Council

Worcestershire Acute Hospitals NHS Trust

Wye Valley NHS Trust

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