Lake Washington School District
Redmond High School
17272 N.E. 104th St., Redmond, WA 98052 | 425 498-7130
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Confidential Drug/Alcohol 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?
   
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