Self-Request for Substance Use Support Services
Instructions: Please complete this form if you or someone close to you needs support with substance use.  You will be contacted by a PPS Certified Alcohol and Drug Counselor (CADC) to discuss your concerns and any need for support services.

* The information collected is confidential and will go directly to a Certified Alcohol and Drug Counselor at Portland Public Schools. This information will not be shared with any school staff or administrators without a signed release of information from the student  or parent/guardian for students under the age of 14.

* Per PPS policy anything shared in this form WILL NOT result in or contribute to any disciplinary process.
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Email *
Your name *
Phone number where you can be reached: *
Who is filling out this form? *
Required
Student name *
PPS ID# (Optional)
School
Grade
Select all that apply:
Gender
Briefly describe your current concern or issue *
What type of support services are you looking for?
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