Parent Substance Abuse Specialist request form
This form is to be used to request a family/parent consult or to refer your student to the NUSD substance abuse specialist: Sarah Jack

*If this is a crisis or you are worried about you or a student's safety (suicidal thoughts/comments or self harm), immediately contact admin, at your students school. If outside of school hours call 911, or click here for crisis support phone numbers and text lines.* 

Please fill out this form if you would like to make a consultation appointment (30-60 min.) with the Substance Abuse Specialist or would like to refer your student (the substance abuse specialist will have to let the student know who referred them). Sarah Jack, the Substance Abuse Specialist will reach out to you (or your student) as soon as possible. . Please note, this will be discrete, but there are exceptions to confidentiality.  Specific limits of confidentiality will be discussed with you or your student by Sarah Jack. All appointments and services provided by the Substance Abuse Specialist are free and take place from 8:00 a.m. to 4:00 p.m.

If you are submitting the form for a consultation Sarah Jack will reach out via email within 48 hours, if referring a student it can take up to a week for Sarah to make contact. 

Contact information for the Substance Abuse Specialist, Sarah Jack
Email: sjack@nusd.org

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Email: *
I understand this is for a non-crisis request for an individual meeting with Sarah Jack, NUSD Substance Abuse Specialist. I further understand it may take up to a week for the Substance Abuse Specialist to respond to my request.
 *
Reason for request
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Name: First and last of person filling out form *
Relation to student *
Student Name: First and Last
Student Grade
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NUSD School Cite
*note, Sarah does not meet individually with elementary school students.
 *
Anything else you would like the Substance Abuse Specialist to know:
All written communication may become part of the educational record. Please be brief, and do not share sensitive information on this form. 
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