Referral for Brief Intervention, Group Intervention and Cessation Services

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Please utilize this form to refer students who have been caught with or have been identified as current commercial users of tobacco (cigarettes, vapes, chew), alcohol, and/or other drugs. Our hope is that these services may be be used in-lieu of suspension and/or reduced suspension for first time offenders. If you would like more information on how to build an Alternative to Suspension Policy on your campus please contact the TUPE Department at 530.528.7391.

Note: Services will be provided at the school, please be prepared to provide a private space for School Mental Health and Wellness staff and referred student(s) only.

Email *

Name of Person Filling Out Referral *

District *

Name of School *

Grade *

What service are you referring this student for? *

Brief Intervention (Individual Intervention for students caught vaping tobacco and/or marijuana))

Healthy Futures (group) ex: Recommended if a group of students is caught vaping

Cessation: For students who express they want to quit vaping or smoking tobacco

Referral to Substance Use Recovery

Required

Describe the presenting issue for why the student is being referred. *

Student Name (First and Last) *

Student Date of Birth *

YYYY

Student Home Address *

Parent Name(s)

Parent Email Address

Parent Phone Number

Have parents/guardians been notified about the referral. There is a formal consent form for Brief Intervention, that schools are responsible for providing to parents.

Yes

Left Voicemail

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