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Student Intervention Reintegration Program

Public Consulting Group, Inc. (PCG), has been contracted by AdCare Educational Institute of Maine with funding from the Maine CDC to enhance the referral database and conduct an evaluation of the SIRP program, which is being implemented across Maine. PCG developed this web-based database to collect and house referrals in one secure place for use by AdCare and community organizations throughout Maine. All data will be kept safe and confidential by PCG.

Create Referral Form
Referral information is sent directly to the SIRP class coordinator.

Personal information from referrals are not recorded by Public Consulting Group (PCG).
Information About Youth
1.
First Name*:
2.
Last Name*:
3.
Gender*:
4.
Date of Birth* (mm/dd/yyyy)
5.
Race/Ethnicity:










6.
Address:
Street*:
City*:
State*:
Zip Code*:
7.
Phone Number*:
8.
E-mail Address:
9.
Name of School and Town:
10.
Any special conditions/accommodations/needs for youth to be engaged in SIRP?


Specify conditions:
Parent(s)/Guardian(s)Information
11.
Name:
12.
E-mail Address:
13.
Phone Number:
14.
Emergency Contact Name:
15.
Emergency Contact Phone Number:
16.
Has parent been notified of Referral?


If Yes, please specify:
If No, please specify why not:
Referral Information
17.
Referral Initiated by:
Name:
Organization:






Other, please specify:
Title:
Phone Number:
(XXX)-XXX-XXXX
E-mail Address:
18.
Reason for Referral:
check all that apply






Specify Other Referral Reason
19.
Month/Year of most recent violation/incident leading to Referral: (mm/yyyy)
20.
Please indicate which local community-based prevention organization you refer to for SIRP.







Other, please specify:
21.
Is youth able to read and respond independently? (May be required to answer survey questions on electronic device.)
22.
What prompted this referral?






23.
What substance(s) are used by youth? (Select all that apply)






Additional Details:
Training
Training Completed:
Cancelled:
Coalition:
Notes: