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Welcome
Adolescents Program
Referral
FAQ
About Us
Our Services
How Can I Start
Careers
Blogs
Contact Us
ADOLESCENTS TREATMENT REFERRAL
Referral Source Information
School District
School Name
Referring Staff Name
Title
-- Select Title --
SAC
Counselor
CST
Social Worker
Other
Phone
Email
Student Information
Student Name
Date of Birth
Grade Level
-- Select Grade --
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Parent/Guardian Name(s)
Parent Phone
Parent Email
Reason for Referral (Check All That Apply)
Suspected substance use
Cannabis use
Alcohol use
Vaping / nicotine use
Prescription misuse
Behavioral concerns
Emotional instability
Anxiety / Depression
School disciplinary incident
Re-entry after suspension
Diversion / juvenile involvement
Other:
Additional Information
Brief Summary of Presenting Concerns
Consent Status
Parent/Guardian notified
Consent form pending
Please note:
Journey To Wellness will obtain appropriate written consent prior to any information exchange.
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Admissions Phone:
732-709-7440
Referral Email:
anna@treatmentnj.net