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





School (if applicable)

School guidance counselor (if applicable)

Can we leave a message with this individual?

Is the referred individual aware of this referral?

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

Parent/guardian preferred name


Parent/guardian email

Parent/guardian phone

Can we leave a message with the parent/guardian?

Who is the best person to contact?

Referral Source

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

Social emotional education and skill development

Parenting Classes

Reason for Referral

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