All fields are optional, but be sure to include an email address or phone number if you would like a response.
(E.g. school, court)
(E.g. counselor, social worker, parent)
Male Female X (transgender and/or gender non-conforming)
(If applicable)
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
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.)
(Include Mandated Referral/Self-Referral if applicable)
