Youth Service Referral Form

4D Adolescent Services Referral Form

Our mission is to empower adolescents aged 14-17 with substance use disorder to find freedom from drugs and alcohol.
Click here for the Young Adult Service Referral Form
4D Recovery's Adolescent Services are designed for youth ages 14-17 who are seeking help with substance use challenges. Our approach combines the opportunity to engage in both peer-based recovery support and clinical services when necessary to ensure that every adolescent develops a tailored pathway toward recovery. Whether you’re a referral agency, guardian, or a young person seeking support, this form guides you through the process to determine if 4D services are the right fit.

Our Philosophy & Approach
- Coordinated Support: We believe in addressing both the social and clinical aspects of recovery. Our services begin with a welcoming orientation that introduces the variety of supports and services available.
- Peer Support: Our Recovery Mentors—individuals who have successfully navigated recovery—share their experiences to inspire and guide youth. Their support fosters a strong recovery identity, clarifies each individual's unique recovery journey, helps build a healthy community, and teaches resource navigation while promoting sound decision-making.
- Clinical Services: Our clinical providers provide evidenced based services that help youth participants equip their toolkit with the skills necessary to achieve long term recovery.
- Family Involvement: Research indicates that participant outcomes are bolstered through active familial involvement. For this reason, both of our service departments require active participation from a family member of the adolescent’s choice, ensuring a supportive environment that extends beyond individual treatment and recovery support services.
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.*

I am experiencing challenges related to substance use.I feel that my substance use is interfering with my school, relationships, or overall well-being.I am seeking support to help me and my family navigate the challenges of recovery.I believe I would benefit from both peer support and professional clinical assessment.I am motivated to make positive changes in my life but need guidance to get started.Other
4D Service Request
Where is the participant located?*

Multnomah CountyClackamas CountyWashington CountyOutside the Tri-Counties
What service(s) is being requested?*

Adolescent Recovery Support ServicesAdolescent Clinical Services
What, if any, other services do you think you need.*

Social SupportASAM AssessmentOutpatient TreatmentResidential TreatmentMental Health TreatmentDetoxVocational / Educational
Contact Information
Individual's Name*

First NameLast Name
Individuals Age*

14151617
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.
Individual's Email*
example@example.com
Individuals Address *
Is this a self-referral?*

YesNo
Has the potential participant consented to you sending this referral?

YesNo
Referral Source

First NameLast Name
Referring Agency Information (if applicable)
Example: Volunteers of America
Referral Category

School SystemParent or GuardianSelf-ReferredOther Community PartnerOther
Anything else we should know?
Reply To: Email
example@example.com
Should be Empty:

4D Adolescent Services Referral Form

4D Recovery Service Assessment

4D Service Request

Contact Information