Referral For 1st Offender Drug Education Groups Referral For 1st Offender Drug Education Groups TO BE COMPLETED BY SCHOOL STAFF Date: * Name: * Name: First Name First Name Last Name Last Name School: * Student ID# * Grade: * Reason for Referral: * Use or possession of alcohol/other drugs or drug paraphernalia and/or under the Influence of alcohol/other drugs or unauthorized drugs/substances. Sale or distribution of alcohol/other drugs Staff comments pertaining to referral: Staff Name * Title: * Preferred method of contact: * Email Phone Fax Email * Phone * Fax * Submit completed 1st Offender Referral and Palmer’s Consent and Confidentiality Release form signed by parent / guardian to: Fax 918.292.8250 or email programs@palmer-tulsa.org Note: Case Manger conducting these services will notify referring school personal once the student has completed 4hrs of required services. School Personal: If you have any questions regarding this process or these services please do not hesitate to contact our office. These drug education groups will be conducted by certified Case Managers; however, Palmer has counselors on hand to assist if needed. Thank you for your services. Palmer Outpatient Services (Southeast corner of 8th and Denver) 222 W 8th St, Tulsa, OK 74119 918.832.7763 office 918-292-8250 fax www.palmer-tulsa.org Submit If you are human, leave this field blank.
