Electronic Referral – Second Chance

1 Student Information

2 Program Information

3 Consent for Participation and Release of Information

4 Emergency Contact Form

When: Select session (The date at the top of the drop down list is the next available student session).
Full Name of Student:*
Student's Name
Current Grade*
Current Age*
Gender*
- Male
- Female
Ethnicity*
- Caucasian
- Hispanic
- African American
- Asian
- Multiracial
Select One*
- Alcohol-Related
- Marijuana – Related
- Tobacco Vaping/e-cig
Reason for Referral (Please give a short description)*
Referral from (please check one)*
- School
- Court
- Self / Parent
Substance Abuse Counselor Email:
Confirm Substance Abuse Counselor Email:
Name of School*
If other, what school?
Name of person referring*
Email*
Confirm Email*
Does the student speak and read English?*
- Yes
- No
If no, what language does the student speak?
Has the student been referred to/attended Second Chance before?*
- Yes
- No
If yes, when?
Date Format: MM slash DD slash YYYY
Who referred him/her?
- School
- Court
- Self/Parent
You will be contacted shortly by a Second Chance instructor to verify eligibility to attend the program a second time.
Parent/Guardian Information
Parent/guardian name (1):*
Parent/guardian (1) address*
Street Address Address Line 2 City State ZIP Code
Parent/guardian name (2):
Address for parent 2 same as above?
- Yes
- No
Does parent have an email?*
- Yes
- No
Parent/guardian email
Address for parent 2:
Street Address Address Line 2 City State ZIP Code
Confirm Parent/guardian email
Parent/guardian phone:*
Home: Work: Cell:
Preferred way to reach parent/guardian (check the one that you will look at for important messages):*
- Email
- Text to cell phone
- Call cell phone
- Call home phone
- Call work phone
Parent/guardian primary language*
Will the parent/guardian need an interpreter?*
- Yes
- No
Signature of Parent/Guardian
Is the parent present to sign this form?*
- Yes
- No
Date*
Date Format: MM slash DD slash YYYY
Printed Name*
Prefix First Middle Last
Click on box to select
Checking this box confirms that the parent has agreed to allow the referral source to check the box below on the parent's behalf.
Click on box to select*
I understand that checking this box constitutes a legal signature confirming that all of the above information is true and accurate.
Signature of Person Referring:
Date*
Date Format: MM slash DD slash YYYY
Title*
Printed Name*
Prefix First Middle Last
*
I understand that checking this box constitutes a legal signature confirming that all of the above information is true and accurate.

Program Information
Please read the information below.
Dear Parent or Guardian,

Welcome to Second Chance, an early intervention, substance use education program. Our goal is to provide an educational experience that will help your child review his/her relationships, understand the harmful effects of using prohibited substances and what led him/her to do so, and help change his/her behavior. Successful completion requires all three of the following.

Student Program:

High School students are required to attend a 3-day program. They will take the Substance Abuse Subtle Screening Inventory (SASSI) on Day 2 (more information regarding the SASSI can be found at: www.sassi.com).
- Time: 8:30 a.m.-3:00 p.m. Arrive between 8:15 and 8:25 a.m.
- Where: Syphax Education Center, 2110 Washington Boulevard, Arlington, VA (Click here for directions).
- Food: Students must bring their own lunch or cash to purchase lunch from the Syphax café. Water and snacks will be served.
Middle School students are required to attend a 2-day program. They will take the Substance Abuse Subtle Screening Inventory (SASSI) on Day 2 (more information regarding the SASSI can be found at: www.sassi.com).
- Time: 8:00 a.m.-2:30 p.m. Arrive between 7:45 and 7:55 a.m.
- Where: Syphax Education Center, 2110 Washington Boulevard, Arlington, VA (Click here for directions).
- Food: Students must bring their own lunch or cash to purchase lunch from the Syphax café. Water and snacks will be served.
High School Spanish-speaking students are required to attend a 2-day program. They will take the Substance Abuse Subtle Screening Inventory (SASSI) on Day 2 (more information regarding the SASSI can be found at: www.sassi.com ).
- Time: 8:00 a.m.-2:30 p.m. Arrive between 7:45 and 7:55 a.m.
- Where: Syphax Education Center, 2110 Washington Boulevard, Arlington, VA (Click here for directions).
- Food: Students must bring their own lunch or cash to purchase lunch from the Syphax café. Water and snacks will be served.
Parent/Guardian Program: Parents/guardians are required to attend a 3-hour program during the week their child attends Second Chance.
- Time: 6:00-9:00 p.m.
- When:
  - High School program: the evening of Day 3 of the student program;
  - Middle School program and High School Spanish-speaking program: the evening of Day 2 of the student program.
  - A Saturday morning parent session may be offered only for extenuating circumstances on a case-by-case basis.
- Where: Stambaugh Health Services Center (DHS), Lower Level, 2100 Washington Boulevard, Arlington, VA (entrance is directly across the street from the student program).
Booster Session: You and your child are required to attend a follow-up booster session approximately 6 - 8 weeks after the student program:
- When: Date to be confirmed at the parent/guardian session.
- Time: A 15-minute appointment between 6:30 and 9:30 p.m. (specific time to be determined).
- Where: Stambaugh Health Services Center (DHS), Lower Level, Rooms B & C, 2100 Washington Boulevard, Arlington, VA (entrance is directly across the street from the student program).
- Food: We will provide pizza and water. You are also welcome to bring your own.
You will receive a reminder phone call, text, or email a few days prior to the start of the student session. If you have any questions or concerns before then, please let me know. We look forward to working with you soon.

Sincerely,

Alvaro Alarcon
alvaro@impel.life
202-644-6812
www.impel.life

Emergency Contact Form
Full Name of Student*
Student's Name
Student’s Personal Contact Information:
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone*
Email*
Confirm Email*
Emergency Contact Information:
Name*
Prefix First Middle Last
Relationship*
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone*
Work Phone
Does the emergency contact have an email?*
- yes
- no
Email
Confirm Email
Medical Information:
Please send an email to Alvaro Alarcon at: alvaro@impel.life and/or call: 202-644-6812 concerning any medical issues including allergies, medications, health concerns, etc.
If your child needs to take any medication during the day, please indicate the name of the medicine, the dosage, and when it needs to be taken. The medication should be in the original container.
Consent*
- I am/we are the custodial parent(s)/guardians of the student named above. In my/our absence, we have left our child in the care of and do hereby authorize the instructors for the Second Chance Program to consent on our behalf to any emergency medical treatment that my/our child may require and I/we agree to bear financial responsibility for such care.
Date*
Date Format: MM slash DD slash YYYY
Parent / Guardian Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Parent / Guardian Name*
First Last
Additional Comments/Questions:

Home:	Work:	Cell:

Parent/Guardian Information

Signature of Parent/Guardian

Signature of Person Referring:

Program Information

Consent for Participation and Release of Information

Emergency Contact Form

Student’s Personal Contact Information:

Emergency Contact Information:

Medical Information: