Student Referral Form

Please fill out this form. For assistance or questions email info@heartlandhighscool.org.

Referrer Information

First name

Last name

Phone

Organization

First Name

Last Name

Birthday

Sex

Parent/Guardian(s) Name(s)

Phone

Address

Grade Level

School District

School Contact Information (phone/email/fax)

Please respond to following questions to the best of your knowledge.

Does student have a history of substance use?

Yes

Are parents/guardians in support of referral?

Yes

Does student express desire to be a part of Heartland High School?

Yes

Has student completed addiction treatment? If so, when and where?

Is student involved in or expected to be involved in aftercare treatment? If so, where?

Does student display a sincere desire to stay sober and continue to work a program of recovery? If so, how is this shown?

Any other wrap around services provided to student such as social worker/therapist? If so, what?

Is student currently receiving special education services? If so, in what area?

Any additional information: