PPS Request for Student Substance Use Services

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Please complete this form if you are interested in requesting service for a student from a PPS Certified Alcohol and Drug Counselor (CADC) or community partner.

* The information collected in this form is confidential and will go directly to the PPS Substance Use Services Team and will not be shared with any PPS school staff or administrators without a release of information signed by the student and/or parents of students under the age of 14.

* Per PPS policy any information provided WILL NOT result in or contribute to any disciplinary process for any student.

Email *

Your name and contact phone number: *

Your relationship to the student (PPS staff member or other support person/your role/school/program/department) *

Student name. *

Student phone number, if known

Guardian name and phone number.

Does the student have insurance? If yes, what type? (insurance is not required for services)

School *

PPS ID#

Grade *

Race

Ethnicity

Gender

Eligibility, if known

Is this a discipline referral? Please note, Insight Class is the primary intervention for Level A discipline. If you wish to refer a student to Insight, please use the Insight referral form on the Student Success & Health page. See next question for factors that would warrant using CADC services in lieu of Insight as a Level A alternative plan. *

Level A

Level B

Level C

Level C+

Other:

For alternative plan referrals-Which of these concerns is true for this student? *

N/A This is not a disciplinary referral

Concern about ongoing substance use

Suspected to be using high risk for a fatal overdose (opiates, sedatives, other pills or street drugs))

Has previously received substance use treatment

Found in possession of multiple substances, and/or large quantities

Significant barriers (not just preference) to attending Insight

Ongoing concerns about being involved in substance related activity on campus

Involved other prohibited or illegal behavior such as shoplifting or tagging.

Struggling with academics and/or attendance

Has been referred to Insight and hasn't completed

Other:

Required

To the best of your knowledge what substances is this student using? *

Marijuana

Alcohol

Nicotine

Psychadelics-LSD, Mushrooms, MDMA

Inhalants

Prescription drugs (using for a high, not as prescribed)

Illegal drugs (cocaine, heroin, meth, etc.)

Don't know

Other:

Required

To the best of your knowledge what is the frequency of student's substance use? *

Once or twice in the last year

Monthly (up to 3x a month)

Weekly (at least once a week)

Daily (or most days)

Don't know

Required

What previous interventions or treatment for substance use has this student received? *

Insight Class

Attending student Student Success Center

Working with an individual counselor around substance use concerns

Attending groups or intensive outpatient treatment for substance use concerns

Attended recovery meetings in the community (such as AA, NA, etc)

Substance Use inpatient or residential treatment

Don't know

None of these

Other:

Required

What are somethings that are going well or strengths of this student/family? *

Parents are involved

Parents support student doing counseling

Has positive connections with adults at school/home/community

Regular attendance

Enjoys some of their classes

Involved with extracurricular activities

Has prosocial hobbies and interests

Has positive peer connections

Open to counseling

Other

Required

Anything else you want us to know about this student or family?

Have you contacted the parent or guardian about this referral? *

Yes

Outcome of contact with parent?

Who would be the best initial contact to further discuss this concern? *

Person making the referral

Parent, Guardian or other Caregiver

Student (over the age of 14)

Other:

If initial contact will be with someone other than person making the referral, please provide the name of the person, their relationship to the student and the best way to reach them including current contact information.

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