Referral Form for Prevention Works Services

All fields are optional, but be sure to include an email address or phone number if you would like a response.

Referred Individual

Preferred name

Legal name

Pronouns





Age







Email

Phone

School (if applicable)

School guidance counselor (if applicable)

May we leave a message?


Is this individual aware of this referral?


Referred Individual’s Parent or Guardian (If 17 or Under)

Parent/guardian preferred name

Pronouns





Parent/guardian email

Parent/guardian phone

May we leave a message with the parent/guardian?


Who is the best person to contact?


Referral Source







Referral source contact name

Referral source role

Email

Phone

Intervention, Program, or Service Needed (Check All That Apply)

Substance use intervention






Enhanced social-emotional skills






LGBTQ+ services






Bullying



Parenting Classes




Other

Reason for Referral

Please provide a short narrative for the reason for referral (child caught using, seeking parenting classes, bullying instance, etc.).