Objectives To describe sexual health behaviors, as well as prior use of and preferences for sexual health services among adolescents in the pediatric Emergency Department (ED). Methods In this cross-sectional study, subjects aged 14-19 years who presented to an urban or suburban ED from a single Midwestern area completed a written survey. The survey included questions on previous sexual activity (PSA), high-risk behaviors (1st sex before age 15, no condom at last sex, substance use at last sex, >3 partners in past 3 months, and >4 lifetime partners) and sexual health service use and preferences. Comparisons of responses between subgroups were analyzed using Chi-square test. Multiple logistic regression was used to identify factors associated with high-risk behaviors. Care preferences were scored using a four-point Likert scale; mean scores were ranked. Results Subjects included 306 adolescents (85% of approached). The mean age was 15.5 years. Almost half (45%) reported PSA and, of those, 63% reported ≥1 high-risk behavior (most commonly 1st sex before age 15 [43%] and no condom at last sex [29%]). Almost all wanted to prevent pregnancy, but only one-third received birth control counseling before sexual debut and 14% reported no contraception at last sex. Younger age was associated with ≥1 high-risk behavior (odds ratio = 3.7; confidence interval = 1.39-9.84). Preferences for care included caring, knowledgeable providers and low/no cost. Conclusions Due to high prevalence of high-risk behaviors among adolescents presenting in the ED, strategies should be developed to link these patients to comprehensive sexual health care.