Referral Form for Prevention Works Services

Referral Source

Name of organization (e.g. school, court)

Referral contact name

Referral contact role

Email

Phone

Referred Individual

Preferred name

Pronouns

She/Her
He/Him
They/Them
Other:

Legal name

Age

Male
Female
X (transgender and/or gender non-conforming)

School (if applicable)

Phone

Intervention/program/service needed

Youth (19 and under) for Intervention/COA Services  Info
Adults (20 and over) for Intervention Services  Info
Youth (12–18) for Awareness Theatre (AT)  Info
Parenting Classes  Info
Impaired Driver Program (IDP)  Info

Reason for referral (check all that apply)

Vaping
Tobacco
Alcohol
Marijuana
Prescription Drugs
Heroin
Cocaine
Methamphetamine
Other Drugs (please specify below)
Enhanced Social-Emotional Skills (i.e. decision-making, assertiveness skills, coping with anxiety, etc.)
Bullying (for the victim, bystander or bully)

Please provide a quick narrative for the reason for referral (vaping on the bus, caught with marijuana, etc.)