Nicotine/Cannabis Prevention Request
If you are a young person or you know one who is struggling with nicotine, cannabis or other drugs, or would just like more information on the topic, please use this form. All requests are confidential. If referring for someone else, we will notify you when we make contact. 
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Name of person making referral:
Name of person who meeting is for:
School of person who meeting is for:
Grade and age of person who meeting is for: 
Reason for Counseling Request
Phone number of person referring 
Email of person referring
Anything else you want us to know?
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