Elevate

Contact Name *

First Name

Last Name

Phone *

(###)

###

####

Individual has been notified of referral *

Yes

No

Youth Name *

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Additional Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Parent/Guardian Address (If different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

There is evidence that youth is using (or suspected to be using ) alcohol, marijuana and/or other drugs. *

Yes

No

Unknown

Youth has received a ticket or other directive to seek services related to alcohol, marijuana and/or other drug use. *

Yes

No

Unknown

Youth is tardy, absent and/or skipping classes to the extent that academic performance and/or behavior is affected. *

Yes

No

Unknown

Youth is struggling and is high risk for substance use, truancy and/or delinquency; youth would benefit from regular one-to-one interaction with a trained mentor. *

Yes

No

Unknown

Other

Yes

No