SIRP

Referral information is sent directly to the SIRP class coordinator.

Personal information from referrals are not recorded by Public Consulting Group (PCG).

Information About Youth

First Name*:

Last Name*:

Sex*:

Male

Female

Other

Prefer not to answer

Date of Birth* (mm/dd/yyyy)

Address:

Street*:

City*:

State*:

Zip Code*:

Phone Number*:

E-mail Address:

Name of School and Town:

10.

Any special conditions/accommodations/needs for youth to be engaged in SIRP?

Yes, please specify:

Specify conditions:

Parent(s)/Guardian(s)Information

11.

Name:

12.

E-mail Address:

13.

Phone Number:

14.

Emergency Contact Name:

15.

Emergency Contact Phone Number:

16.

Has parent been notified of Referral?

Yes

If Yes, please specify:

If No, please specify why not:

Referral Information

17.

Referral Initiated by:

Name:

Organization:

School Resource Officer

School (Other)

Community Referral Source/Programming

Law Enforcement

Juvenile Community Corrections

Other

Other, please specify:

Title:

Phone Number:
(XXX)-XXX-XXXX

E-mail Address:

18.

Reason for Referral:
check all that apply

Self-Referral to Program

Parent/Guardian Referral

Violation of School Drug/Alcohol Policy

Arrest or Citation involving drugs and/or alcohol

Violation of Probation

Reports (by self or other) of being impaired within the last 30 days

Other, please specify:

Specify Other Referral Reason

19.

Month/Year of most recent violation/incident leading to Referral: (mm/yyyy)

20.

Is youth able to read and respond independently? (May be required to answer survey questions on electronic device.)

Yes

Unsure

21.

What prompted this referral?

22.

What substance(s) are used by youth? (Select all that apply)

Alcohol

Cannabis

Tobacco/Nicotine

Prescription Drugs

Other

None

Unsure

Additional Details:

Training

Training Completed:

Cancelled:

Coalition:

Notes: