Youth Service Referral Form

4D Adolescent Service Referral Form

4D's Adolescent Program provides a variety substance use recovery support services to people between the ages of 14-17. This form can be completed by either an agency, guardian, or a person seeking recovery support. We have provided a short self-assessment that will help interested parties determine if 4D services will be an effective choice.
The 4D Youth Recovery Program specializes in helping adolescents with substance use issues find freedom from drug and alcohol use with non-clinical peer-based recovery support services. Our program is specifically designed to help youth who identify wanting to resolve their substance use problems.

Our strategy is to show youth wanting to stop using drugs and alcohol that it is possible by sharing our lived-recovery experience, introducing them to other youth in recovery, and helping them and their families connect with additional resources.

Peer Support: 4D Youth Peers are people in recovery who understand the unique challenges adolescents with substance use face in finding recovery. Our lived experience combined with best-practice peer training gives us a unique ability to connect with youth and guide them in their recovery process.

Peer Support Goals:
- Help youth develop a recovery identity
- Role model recovery and inspire youth to work towards healthy living
- Reduce impulsive decisions and mitigate the crisis
- Increase youth goal achievement
- Coach youth through challenging times
- Help youth navigate resources
Click here for the Young Adult Service Referral Form
4D Recovery Service Assessment
Generally, people wanting to engage in our services meet at least one of the following criteria. If none of these these apply to you, then 4D services are not likely to meet the need you are trying to address. Please check all that apply.*

Using drugs and/or alcohol is causing issues in my life and I want to stop it from happening.I want to stop using drugs and/or alcohol.I am being pressured to address my drug and/or alcohol use by someone/something else (friends/family/court/school/employer/etc.).4D is being suggested by a social service provider.I am unsure if drug and/or alcohol use is a problem for me, but I am interested in learning more about what recovery is.Other
If you answered yes to any of the previous statements, please continue.
4D Service Request
What area would you like to receive services in?*

Multnomah CountyClackamas CountyWashington CountyOutside the Tri-Counties
What type of 4D recovery support do you need?*

Recovery Mentoring (someone in recovery who helps you find/sustain recovery)Mutual-Aid Recovery Support (12 Step and other types of recovery meetings)
What, if any, other services do you think you need.*

DetoxResidential TreatmentMental Health TreatmentHousingEmploymentEducationPrimary CareDentalOther
Contact Information
Individual's Name*

First NameLast Name
Individuals Gender *
Individual's Phone Number*
If the individual does not have a phone number, please fill form out with contact info the individual can provide.
Individuals Age*

14151617
Individual's Email*
example@example.com
Individuals Address *
Referring Agency Information (if applicable)*
Example: Volunteers of America
Referral Category

School SystemParent or GuardianSelf-ReferredOther Community PartnerOther
Anything else we should know?
Should be Empty:

4D Adolescent Service Referral Form

4D Recovery Service Assessment

If you answered yes to any of the previous statements, please continue.

4D Service Request

Contact Information