SACADA TREE Program Referral Form

SACADA TREE Program Referral Form
Date of Referral

MonthDayYear
Date
Name of Person Making Referral
Referring agency/organization
Phone Number
Please enter a valid phone number.
Reason for Referral
Additional Comments
STUDENT INFORMATION
Student Name

First NameLast Name
Student Date of Birth

MonthDayYear
Date
Student's Age
School Currently Attending
Student Grade
Parent Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Phone Number
Please enter a valid phone number.
Parent Email
example@example.com
Best Time to Contact Parent
Parent Preferred Language
Was this Parent Advised of Referral?

YesNo
Behavioral Concerns:

Substance UseDisrespectful BehaviorPeer/Social ProblemsStealingFamily ProblemsInappropriatenessFightingBullyingDecline in GradesLegal ProblemsOther
Name of Minor Child:
Age:
Date of Birth?

MonthDayYear
Date
We, the undersigned parent(s) or legal guardian(s) of the above-mentioned minor do give consent to authorizeschool location to release the following information.
Please select multiple.

Student Demographic InformationSchool AttendanceRecommendations & ReferralsDisciplinary Alternative Education Program (DAEP) ReferralGrade LevelFollow-up InformationOther Information:
For the purpose of:

Screening for Substance use disorderEnrollment into prevention/ Intervention servicesKeeping Family Members informedContinuity of CareConnecting me with additional servicesKeeping the Court / Probation informedOther:
This consent expires on:date of event (up to one year from today).
Confidentiality: Except for the above, SACADA will keep all information gained through the assessor/client relationship strictly confidential, except as required by law or in situations deemed potentially life-threatening. Federal and state laws and regulations may also protect the confidentiality of your participation in this program. The violation of federal requirements is a crime and suspected violations may be reported. Federal regulations do not protect from disclosure of information related to a client's commission of a crime against SACADA services, property or personnel, or report under state laws of suspected child abuse or neglect. (See 42 U.S.C. 290dd-3 and 290ee-3 for federal laws and 42 CFR Part 2 for federal regulations.)

Notice to Receiving Agency or Person: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal Rules prohibit any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug treatment patient.
Minor Student Name Printed:
Date

MonthDayYear
Date
Parent Name Printed:
Date

MonthDayYear
Date
Staff Printed Name:
Date

MonthDayYear
Date
Should be Empty: