Resilience & Recovery Project---Substance Abuse Intervention Request Form
IMPORTANT NOTE:  Please notify Melissa Anderson at BCOE, via email (manderson@bcoe.org)
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Name/School ID Number:
Date of Birth:
MM
/
DD
/
YYYY
Grade Level:
School of Attendance:
Referring Person's Name:
Referring Person's School Site:
Date:
MM
/
DD
/
YYYY
Parent/Guardian Contact Information:
Student Contact Information:
Have the parents/guardian been contacted?  
Clear selection
Reason for Request
Level of Concern:
Clear selection
Current Services Provided:  (If known)
Is student willing and able to do virtual meetings?
Clear selection
Submit
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This form was created inside of Butte County Office of Education. Report Abuse