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Lake Washington School District
Redmond High School
17272 N.E. 104th St., Redmond, WA 98052 | 425 936-1800
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Redmond High > Counseling Center > Confidental Drug/Alcohol Referral Form
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Confidential Referral Form
(* indicates a required input field)
Concerned Student Identification
First Name *      
Last Name *
Grade Level *
Urgency Level *
Referral Date *
Description of Concerns
Possible Alcohol, Tobacco and Other Drug Specific Behaviors
None Student has reported this to me Self Reported (only mark if referring self) Witnessed Suspected Explanation
Selling; Delivering
Possession of alcohol, tobacco or other drugs
Possession of drug paraphernalia
Use of alcohol, drugs
Intoxication
Physical signs, symptoms
Associates with apparent drug users
Talks freely about drug use; bragging
Wears drug related jewelry
Has drug art work or doodles
Others? (Please indicate specifics in the area below)
Others :
Academic Performances (check all that apply)





Comments about Academic Performance :
Behavior / Conduct (check all that apply)








Comments about Behavior / Conduct :
Attendance (check all that apply)





Comments about Attendance :
Affect (check all that apply)























Comments about Affect :
If you have discussed any of these concerns with this student, please comment
YES - If yes, what was their response?
What other actions have you already taken?
What actions do you contemplate taking?
Other comments?
   
The Lake Washington School District does not discriminate on the basis of race, color, national origin, sex, disability, age, gender, marital status, creed, religion, honorably discharged veteran, military status, sexual orientation including gender expression or identity, the presence of any sensory, mental or physical disability, or the use of a trained guide dog or service animal by a person with a disability, in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups. Complete policy statement
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