EXTERNAL AGENCY REFERRAL INTO KIRKLEES SEXUAL HEALTH SERVICE Kish.sexualhealth@nhs.net

DATE & TIME OF REFERRAL Click here to enter a date. Time: Click or tap here to enter text.

REFERRING AGENCY	REFERRER’S NAME & ROLE
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CONTACT NUMBER	E-MAIL ADDRESS
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ADDRESS OF REFERRING AGENCY	Click or tap here to enter text.

Please confirm the service user has consented to this referral

Yes ☐ No ☐

FULL NAME	Click here to enter text.
DATE OF BIRTH	Click or tap to enter a date.
CURRENT ADDRESS	Click here to enter text.
LAC?	Yes ☐	No ☐
CONTACT NUMBER	Click here to enter text.

DISABILITY	PREFERRED GENDER	SEXUALITY	RELIGION
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ETHNICITY (Ethnic category 2011 census)
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PREFERRED METHOD OF CONTACT please enter the preferred way to contact the individual being referred
Phone contact with Patient directly	Yes ☐ No☐
Can we leave a voicemail	Yes ☐ No☐
Can we send text messages	Yes ☐ No☐
Send correspondence to patients address	Yes ☐ No☐
Phone contact with allocated worker	Yes ☐ No☐
If yes and different to Referrer, please give details below:
Name:	Click here to enter text.
Role:	Click here to enter text.
Contact numbers:	Click here to enter text.

Does this patient require an interpreter?	Yes ☐	No ☐

If yes, Please state language	Click here to enter text.

REASON FOR REFERRAL include details of additional vulnerabilities
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DETAILS OF INFECTIONS
Infection Name	Chlamydia Yes ☐ No☐
Gonorrhoea Yes ☐ No☐
TV Yes ☐ No☐
HSV Yes ☐ No☐
BV Yes ☐ No☐
Hepatitis B Yes ☐ No☐
HIV Yes ☐ No☐
Syphilis Yes ☐ No☐
Date of Testing	Click here to enter a date.
Site of infection (if applicable)	Click here to enter text.
Treatment details (if applicable)	Click here to enter text.

REFERRAL FOR LONG ACTING REVERSIBLE CONTRACEPTION (LARC)
LARC Please tick type of LARC requested and reason for referral below	IUD insertion ☐ removal ☐
IUS insertion ☐ removal ☐
Implant insertion ☐ removal ☐
STI screening completed Yes ☐ No☐
Counselled about method Yes ☐ No☐
Reason for referral	Choose an item.
Current contraception	Click here to enter text.
Other relevant information	Click here to enter text.

PLEASE GIVE DETAILS OF ANY OTHER AGENCIES INVOLVED WITH THIS PERSON
Agency	Contact Name & Role	Contact Numbers/ e-mail
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Agency	Contact Name & Role	Contact Numbers/ e-mail
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Agency	Contact Name & Role	Contact Numbers/ e-mail
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Please send referral to kish.sexualhealth@nhs.net

**Please send this form from a secure (nhs.net) e-mail address**

END OF REFERRAL FORM