Intervention Counselor Referral Form
Substance Use Intervention
Hanover County Public Schools
STUDENT NAME
Last, First
Your answer
Student ID #
Your answer
What is the home school for this student?
Kierstin Montano, Intervention Counselor serves (PHHS, LMS, HHS, OKMS) Majken Whitaker, Intervention Counselor serves (AHS, CMS, LDHS, SJMS)
Grade Level
6
7
8
9
10
11
12
Other
Grade 
Date of Birth
MM
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DD
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YYYY
Contact #1
Last, First (state relationship)
Your answer
Home Phone Number for Contact #1
Please enter the phone number that you used to successfully reach parent and label (w), (c), (h)
Your answer
Address for Contact #1
Your answer
Contact #2
Last, First (state relationship)
Your answer
Home Phone Number for Contact #2
Please enter the phone number that you used to successfully reach parent and label (w), (c), (h)
Your answer
Address for Contact #2
Your answer
Date of Referral
Date that you are turning in the paperwork to Intervention Counselor after speaking with Parent/Guardian.
MM
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DD
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YYYY
Student's Assigned School Counselor
Referent
Last, First
Your answer
Referent's Position
What best describes your role with this student?
If this is an Administrative Referral please state date of parent contact.
Student has violated the alcohol/drug code and is mandated to meet with the Intervention Counselor for support and referral information. Parent has been instructed to contact the Intervention Counselor within 24 hours. Administrator follows up with a phone call or e-mail notifying the Intervention Counselor that this form has been completed.
MM
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If this is an Administrative Referral please state date the student will return from suspension.
If a student is being recommended for expulsion or long-term suspension for an alcohol/drug offense, please complete the referral and follow up with a phone call or e-mail to your Intervention Counselor even if you do not expect the student to return to your building.
MM
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Faculty/Staff Referral: Date of parent contact
Parent/Guardian has been contacted by staff member and behaviors of concern have been communicated to parent by staff member. Remember you are just stating observations regarding behaviors and not defining cause of behaviors. Intervention Counselor will not make contact with the student until parent contact has been made.
MM
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DD
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YYYY
Specific Reason(s) for Referral:
Please be objective in your response.
Your answer
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