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Student Self-Referral Form Only
Thank you for taking this next step in your quitting journey. Please know you are not alone, we can help. Please fill out the information below and someone will be in contact with you soon.
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Student Name
*
Your answer
Current School Attending
*
Your answer
Do your parents/guardians know you use?
*
Yes
No
Maybe
What is the best way to get in contact with you?
*
Your answer
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