Referral Form

Prevention Connection Virtual Hub – Teen Intervene – Referral Form

Date

Referral Information:

Name of Person submitting referral: *

Agency/School/Organization

Email *

Title

Phone Number

Youth Name *

County

Email *

Grade

Youth notified of 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

LEAF
189 Main Street #201
Oneonta, New York 13820

Phone: (607) 432-0090

Fax: (607) 432-3195