Teen Intervene Referral Form
This form is used to refer a teen 12-17 years old to Seaway Valley Prevention Council's Teen Intervene program. 

Teen Intervene is a harm reduction program designed to work with teens ages 12 – 17 years old experiencing problems related to mild to moderate use of alcohol, tobacco, or other drugs. The referred teen works one-on-one with an educator to (1) identify the reasons why they have chosen to use alcohol or other drugs, (2) examine the effects of substance use in their lives, and (3) learn skills to make healthier choices.
First, tell us about you.
What is your name? *
What is your email address *
What is your telephone number? *
What is today's date? *
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What is your relationship to the teen that you are referring? *
Now tell us about the teen that you are referring.
What is their name? *
What school do they attend?
What grade are they currently in? *
What is their birthdate? *
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Where would they like to complete the program? *
What day(s) of the week work best with their schedule? *
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What time(s) of the day work best with their schedule? *
Required
Have they recently experienced any consequences resulting from their substance use? *
Required
What is the primary/main reason why you are referring this teen? *
Which of the following reasons are related to why you are referring this teen? *
Required
Please tell us if the teen that you are referring is facing any of the following concerns. *
Required
Please tell us about any other mental health or behavioral concerns, if any.
Please list any additional programs or organizations that the teen or their family currently participates in, if any.
Please tell us any other information that you think we should know about.
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