Referral for 2nd Offender Drug / Alcohol Assessment Referral For 2nd Offender Drug Education Groups TO BE COMPLETED BY SCHOOL STAFF Date: * Student Name: * Student 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 referral to Palmer - Fax 918.292.8250 or email programs@palmer-tulsa.org Note: Upon parent / guardian signing a Release of Information (ROI) at intake counselor will send referring staff member an assessment report with treatment recommendations. Information for Parents / Legal Guardians: Parent / Guardian must contact Palmer Outpatient Services to make an appointment for the assessment. The assessment includes a urine drug analyses completed at Tulsa Drug Screening Inc. Intake counselor will refer student to TDS upon completion of assessment. Cost of urine drug analyses is $16.00; however, if this is going to be a barrier Palmer can assist. The type of assessment completed will determine on the age of the student (ASI or CAR) and is at no cost to the family. Legal Guardians must bring proof of guardianship with them at the time of appointment. Palmer can assist with attendance letter if needed. Palmer Outpatient Services(Southeast corner of 8th and Denver)222 W 8th St,Tulsa, OK 74119918.832.7763www.palmer-tulsa.org Submit If you are human, leave this field blank.
