Parental Substance Abuse Crisis Referral Form
Referral Information
Date of Referral
Referrer Name
Referrer Organization/Agency
Referrer Contact Information
Parent/Guardian Information
Parent/Guardian Name
Date of Birth
Address
Phone Number
Email
Child(ren) Information
Child(ren) Name(s) and Age(s)
Substance Abuse Details
Type(s) of Substance Used
Duration/Frequency of Use
Current Status (e.g., intoxicated, withdrawal, etc.)
Crisis Description
Describe the Current Crisis
Immediate Risk or Harm Identified
Actions Taken
Actions Already Taken (if any)
Services Requested
Type of Intervention/Support Requested