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)

May we leave a message?

Yes
No

Is this individual aware of this referral?

Yes
No

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

Parent/guardian preferred name

Pronouns

She/Her
He/Him
They/Them
Other:

Parent/guardian email

Parent/guardian phone

May we leave a message with the parent/guardian?

Yes
No

Who is the best person to contact?

Parent/Guardian
Client

Referral Source

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

Referral source contact name

Referral source role

Email

Phone

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

Substance use intervention

Vaping
Nicotine
Alcohol
Marijuana
Other Drugs:

Enhanced social-emotional skills

Decision Making
Assertiveness Skills
Coping With Anxiety
Goal Setting
Other Skills:

LGBTQ+ services

Navigating Coming Out
Educational Material
Coping Skills
Parent Support
Other LGBTQ+ Topic:

Bullying

Victim
Bystander
Bully

Parenting Classes

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

Other

Children Living in a Chemically Dependent Home

Reason for Referral

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