Referral Form for Prevention Works Services

Referred Individual

Preferred name

Legal name

Pronouns

She/Her
He/Him
They/Them
Other:

Age

Male
Female
Nonbinary
Genderqueer
Transgender
Other:

Email

Phone

School (if applicable)

School guidance counselor (if applicable)

Can we leave a message with this individual?

Yes
No

Is the referred individual aware of this referral?

Yes
No

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

Parent/guardian preferred name

Pronouns

She/Her
He/Him
They/Them
Other:

Parent/guardian email

Parent/guardian phone

Can we leave a message with the parent/guardian?

Yes
No

Who is the best person to contact?

Parent/Guardian
Client

Referral Source

Self
Parent/Family/Friend
School
Court/Probation
DHHS
Other:

Referral source contact name

Referral source role

Referral source email

Referral source phone

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

Substance use intervention

Vaping
Nicotine
Alcohol
Marijuana
Other Drugs:

Children Living in a Chemically Dependent Home

Social emotional education and skill development

Decision Making
Assertiveness Skills
Coping With Anxiety
Goal Setting
Managing Emotions
Bullying
Relationships
Other Skills:

Parenting Classes

Triple P Ages 0–12
Triple P for Teens
Triple P Stepping Stones
PAX Community Tools

Reason for Referral

Please provide a short narrative for the reason for referral (child caught using, SEL support, parenting, etc.).