Referral Form

Prevention Connection Virtual Hub – Teen Intervene – Referral Form

Date

Referral Information:

Name of Person submitting referral: *

Agency/School/Organization

Email *

Youth Information

Title

Phone Number

Youth Name *

County

Email *

Grade

Youth notified of referral

Reasons for Referral

Age

Phone Number

School District

Relationship to Youth

Parent(s) notified of referral

Alcohol use

Marijuana use

Tobacco use/Vaping

Prescription Drugs

Gambling

Other Drug use

What prompted you to make this referral

If you have not notified youth of referral, what is your reason?

Additional Information

Submit

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Contact Us

LEAF
189 Main Street Ste. 101
Oneonta, New York 13820

Phone: (607) 432-0090

Fax: (607) 432-3195