Resilience & Recovery Project---Substance Abuse Intervention Request Form

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IMPORTANT NOTE: Please notify Melissa Anderson at BCOE, via email (manderson@bcoe.org)

Name/School ID Number:

Date of Birth:

YYYY

Grade Level:

School of Attendance:

Referring Person's Name:

Referring Person's School Site:

Date:

YYYY

Parent/Guardian Contact Information:

Student Contact Information:

Have the parents/guardian been contacted?

Yes

I don't know

Clear selection

Reason for Request

alcohol

nicotine (cigarettes, vaping, chew, etc.)

Marijuana

Other drugs (prescription opiates, meth, heroin, etc.)

Level of Concern:

Low

Moderate

High

Clear selection

Current Services Provided: (If known)

none

private therapy

behavioral health

Youth for Change, NVCSS, Victor Community Supports, Tribal Health

fire recovery counseling

Other:

Is student willing and able to do virtual meetings?

Yes willing and able

Not willing

Not able due to access issues

Clear selection

Submit

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