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Section Twenty

Application and Referral Information

SPECIAL NEED PROGRAMS

ELEMENTARY

Special Needs Program

The focus of the Special Needs Program is to enhance the child’s functional life skills and maximize intellectual ability.

Criteria for Admission to the Special Needs Program

There should be evidence of appropriate assessments showing that the child meets the criteria for an intellectual exceptionality. Weight will be granted to profound, severe and moderate developmental disabilities. Severe delays in academic functioning should also be evident. Relevant information should suggest that the child’s needs cannot be met in a regular classroom. A student, with mild developmental disabilities, would be expected to be accommodated in his/her home school.

There should be evidence of appropriate assessments with follow-up program and classroom modifications in the student’s OSR and a Lakehead District School Board IPRC where a student was identified as intellectually exceptional.

Program Locations: Ecole Gron Morgan, Vance Chapman, Westmount

Multi-Needs Program

The focus of the Multi-Needs Program is to enhance the child’s functional life skills, physical development, and to maximize intellectual ability.

Criteria for Admission to the Multi-Needs Program

The physical needs of the child are severe enough to necessitate special equipment and special assistance. Severe delays in academic functioning should also be evident.

There should be evidence of appropriate assessments with follow-up program and modifications. A Lakehead District School Board IPRC is required for admission to the program where the student was identified as having Multiple Disabilities.

Multi-Needs Program Location: Algonquin, Westmount

SPECIAL NEED PROGRAMS

SECONDARY

Pre-Workplace Program

The focus of the Pre-Workplace Program is to enhance the student’s functional life skills and maximize intellectual and academic abilities. The students in the program will be working towards an Ontario Secondary School Certificate of Achievement.

Criteria for Admission to the Pre-Workplace Program

There should be evidence of appropriate assessments showing that the student meets the criteria for an intellectual exceptionality. Significant delays in academic functioning should also be evident. Relevant information should suggest that the student’s needs cannot be met in a regular secondary program.

There should be evidence of appropriate recent assessments with follow-up program and classroom modifications in the student’s OSR and a Lakehead District School Board IPRC where a student was identified as intellectually exceptional.

Program Locations: Superior CVI, Westgate CVI, Hammarskjold High School

Special Needs Program

The focus of the Special Needs Program is to enhance the student’s functional life skills, and physical development, and to maximize intellectual and academic abilities. Students in this program will be working towards an Ontario Secondary School Certificate of Accomplishment.

Criteria for Admission to the Special Needs Program

The intellectual and functional needs of the student are severe enough to necessitate special programming. Severe delays in academic functioning should also be evident.

There should be evidence of appropriate assessments with follow-up program and modifications. A Lakehead District School Board IPRC is required for admission to the program. The student should be identified as having an developmental disability with a diagnosis of intellectual disability at least in the moderate range.

Special Needs Program Locations: Hammarskjold High School, Westgate CVI

SECONDARY (cont.)

Multi-Needs Program

The focus of the Multi-Needs Program is to enhance the child’s functional life skills, physical development, and to maximize intellectual ability. Students in this program will be working towards an Ontario Secondary School Certificate of Accomplishment.

Criteria for Admission to the Multi-Needs Program

The physical needs of the child are severe enough to necessitate special equipment and special assistance. Severe delays in academic functioning should also be evident.

There should be evidence of appropriate assessments with follow-up program and modifications. A Lakehead District School Board IPRC is required for admission to the program where the student was identified as having Multiple Disabilities.

Multi-Needs Program Location: Westgate CVI

APPLICATION FORMS FOR SPECIAL AND MULTI-NEEDS PROGRAMS

Student Name: DOB:

Sending School: Expected Starting Date:

Attending Specialized Program Regular Program

Program applied for:

O Elementary Special Needs program O Elementary Multi-Needs program O Secondary Pre-Workplace program O Secondary Special Needs program O Secondary Multi-Needs program --------------------------------------------------------------------------------------------------------------------- Referral Checklist

O Contact with Parent Date:

O Referral Form Date:

O OSR summary/search Date:

O IEP Date:

O Full Learning Assessment Date:

O Other Relevant Assessments Date:

O Exceptionality Date:

O Autism Report (i.e., IBI program) Date:

Referral Process:

• referrals are to be sent to the Special Education Secretary, Victoria Park Training Centre one week prior to the Special Class Placement Meeting (held once a month)

• facilitator to be available and accessible by phone during meeting in case there are questions or issues that arise

• Chair of the committee will contact the school with the decision re: placement

• the school will arrange a Central IPRC and invite the Special Education Officer after the committee has made a decision to approve a placement in a special class

Committee Members:

• Administrators of the schools where special classes are situated

• Representative of the Board (Special Education Officer)

• Principal without a Special Class Program (Chair of the Committee)

• Board’s Consulting Psychologist

REFERRAL FORM FOR SPECIAL CLASS PLACEMENT

Name: D.O.B.

School: Grade:

Parent(s)/Guardian: Phone

Address: Date:

This student meets the criteria for: O Special Needs-Elementary O Multi-Needs - Elementary O PWP - Secondary O Special Needs - Secondary O Multi-Needs - Secondary

1. Identify and describe major concerns regarding the student.

2. Outline the strategies that have been tried while working with the student (note intervention, duration and results).

3. Identify the strengths and/or abilities of the student.

4. List the student’s physical limitations or special needs.

5. List any specialized equipment and support services needed (include present level of

services).

6. Additional/Relevant Information:

Principal’s Signature:

Date:

DAY TREATMENT PROGRAM

REFERRAL PACKAGE

For further information, contact Program Manager Day

Treatment Program Children’s Centre Thunder Bay

343-5046

September 2017

Table of Contents

Mission Statement and Goals Day Treatment Program Description

Making a Referral and Admission Process

Day Treatment Program Referral Form

Children’s Centre Thunder Bay Day Treatment Program

Mission Statement The Day Treatment Program provides Children's Mental Health Services and educational services for children who are experiencing severe social, emotional and/or behavioural difficulties in the elementary school setting. The Program provides two models for service delivery: the Assessment and Consultation model and the Primary and Junior Treatment and Consultation model in three locations. The program believes that attainment of its objectives lies in collaboration with the multidisciplinary team, the parent/guardians and the community school. It encourages full participation at the beginning and throughout all stages of the program.

Goal of the Program The programs provide a therapeutic education setting where the underlying goal is to improve the child's ability to function successfully in the community school setting. In order to address this goal, the programs will:

• focus on the strengths of the child

• teach adaptive and coping skills to improve social interactions

• promote self-esteem and build confidence

• identify the academic skills and learning style of the child

• assist the parent/guardian and the home school in understanding the child's difficulties

• work with the parent/guardian in making changes in the home and community that support the child's ability to function in the school setting

• assist the home school in developing a plan which best meets the child's needs.

Prior to making a referral to the Day Treatment Program, it is expected that there have been significant interventions attempted at the school level and that the child/youth's needs continue to be beyond what school resources can manage.

This program is conducted through a Memorandum of Agreement negotiated between Children’s Centre Thunder Bay and Lakehead District School Board. Once it is agreed that a child should be admitted, transportation arrangements will be made through the local boards of education.

DAY TREATMENT PROGRAM (CD Howe Public School)

This program is intended to provide an intensive multi-disciplinary assessment of the referred child, family and pertinent environmental factors for students experiencing serious behavioral difficulties within their school setting. Services will be provided in a specialized classroom setting for five months. In exceptional circumstances, this period may be extended for cases requiring additional assessment. Assessments may include: psychological (behavioral/personality), medical, social, emotional and family assessments. Academic programming will focus on improving literacy and numeracy skills. The Discharge Summary report will summarize assessment information and progress of both the child and the family. As well, the Discharge Summary will make recommendations relative to the child's referring issues.

In order to provide the most effective service to families, the program provides sessions with the Family Worker to assist parents in managing and dealing with their child's social and emotional needs.

Admission Criteria (Assessment & Consultation Program)

For admission to the Assessment and Consultation Program, the child will:

• be functioning at or above the borderline level of intelligence

• demonstrate a moderate to severe level of social, emotional or behavioural problems

• have a profile that indicates that a comprehensive mental health assessment is necessary

• be eligible to attend elementary school on a full time basis

• be between the ages of 6 years and 11 years

• have a commitment of the parent to participate in the family component of the program

Exclusion Criteria

A child/youth will be excluded from the program if they:

• are functioning below the borderline level of intelligence

• have a primary exceptionality other than behavioural Discharge Criteria

• Assessments are complete

• The home school has been informed of the assessment results with recommendations for programming

Programs are voluntary and require parental consent for involvement. The program considers and maintains that the parents and the home school principal are the "referring agents" for service. The program operates with a partnership between the family, the teacher and the principal of the referring school, and program staff, in understanding and working with the child's difficulties.

Referrals are initiated by:

1. Completion of a referral form for the specific program as included in this

package. 2. Completion of academic testing and summarized results included in an academic

report. Such reports are only valid if they have been completed within six months of making a referral. This information will assist with completing a learning assessment if it is deemed to be required. The sending school has the responsibility for financing a full learning assessment if it becomes evident that an assessment is required during the placement.

3. Forwarding it to (by mail or fax): Program Manager, Day Treatment Program

283 Lisgar Street Thunder Bay, Ontario P7B 6G6 Fax: 343-6355

Admission Process:

1) Referrals are prioritized based upon when the referral was first made, the

severity of the presenting concerns, and the number of referrals from a given school.

2) Program Psychological Associate will meet with the family to gather their input,

request a case conference with the school staff to gather their input, review the student's OSR, and distribute Intake Questionnaires for completion. An Admission report will be compiled and presented to the Admission Review Committee.

3) The Admission Review Committee is a decision making body established to

review and prioritize referrals to the program. Membership on the committee consists of Principals (Lakehead District School Board), Program Manager (Day Treatment Program), and the CCTB/LDSB Consulting Psychologist.

4) Parents and school staff are notified of the decision of the Admission Review

Committee by telephone and through a follow-up letter. 5) Plans may then be made for admission of the student to the program, or they

may be placed on a waiting list until a placement becomes available. Every effort will be made to recommend alternatives on an interim basis, if the student must wait to be admitted.

Children’s Centre Thunder Bay Day Treatment Program

Referral Form

The goal of the Children’s Centre Thunder Bay (CCTB) Day Treatment Program (DTP) is to provide effective interventions

which enhance a student’s ability to function in a regular school environment. The DTP is a collaborative mental health

program by CCTB and the school system, designed to work with students within their family. Active participation and

involvement of the student’s parent/ guardian in CCTB services is a necessary requirement before a student is accepted

into the program.

Student Information

Name of Child:

Date of Birth:

Address and Postal Code:

Phone Number:

Current School:

Grade (at time of referral):

Date of Referral:

Gender:

Referral Source

Name

Position

School/Agency

Phone Number

Email Address

Contact Person for Ongoing Involvement

Name Position School/Agency Phone Number Email Address

Parents/Guardians

Name Address/Postal Code Phone Number(s)

Home Work/Mobile

Please place a check mark in the box to indicate the student’s current academic performance in the following skill

areas:

Below

Average Average

Above

Average

Reading skills ☐ ☐ ☐

Reading Comprehension ☐ ☐ ☐

Language- Receptive ☐ ☐ ☐

Language- Expressive ☐ ☐ ☐

Mathematics ☐ ☐ ☐

Other: __________________________________ ☐ ☐ ☐

Please place a check mark in the box to indicate the severity of the problems if they are present.

Mild Moderate Severe

Anger/ Explosiveness ☐ ☐ ☐

Anxieties/Worries/Fears ☐ ☐ ☐

Aggression ☐ ☐ ☐

Defiance of adult authority ☐ ☐ ☐

Emotional Reactivity/Problems with Routine Change ☐ ☐ ☐

Inattention (inability to stay on task) ☐ ☐ ☐

Impulsivity ☐ ☐ ☐

Sadness ☐ ☐ ☐

Social problems ☐ ☐ ☐

Other: ______________________________ ☐ ☐ ☐

Other: ______________________________ ☐ ☐ ☐

Presenting Issues (describe primary concerns and feel free to attach another sheet if necessary):

1.

2.

3.

Please list all of the school based intervention strategies (i.e., Tier 1, 2 & 3) that have been attempted with this student

prior to making a DTP referral.

1.

2.

3.

4.

5.

Checklist of Attached Documents

Referral package completed and signed by parent or guardian (Required)

WIAT - most recent (within 6 months) Date:

Or

Most Recent Report Card and DRA (Developmental Reading Assessment), & Math Baseline (Required)

Individual Education Plan (required)

Has this student been identified? Please attach most recent IEP:

Behaviour ☐ Communication ☐ Intellectual ☐ Multi ☐ No ☐

Safety Plan/Behaviour Success Plan or Student Support plan

Learning Assessment (if completed) Date:

Other:

Please Note:

Involvement in this program cannot proceed without voluntary parental consent and active parent participation in treatment services. The Day Treatment Program information is to be shared with parents/guardians and is available at www.childrenscentre.ca under CHILD or YOUTH/TEEN headings and within the CCTB Day Treatment Service Delivery Manual.

This program is reserved for children with significant behavioural and social difficulties or for children with assessment and/or treatment needs.

Schools making referrals have exhausted the full continuum of Tier I and Tier II interventions prior to making a Day Treatment Referral.

http://www.childrenscentre.ca/

Lakehead Public School Board and Thunder Bay Catholic District School Board referrals should

to be sent to the respective Special Education Officer/Coordinator prior to being forwarded to the

CCTB Intake Program (343-5000).

The DTP’s hours are modified. The school day runs from 9:00am -2:00pm or 9:15am to 2:15pm, depending on the assigned classroom.

The Day Treatment Program will make active efforts to support the student’s transition both into the Day Treatment classroom as well as transition back to their home school.

The Day Treatment Program requires family involvement. Parents/guardians should be aware that their child’s placement in the program will be contingent upon their involvement with intervention services on an ongoing basis.

The Program Manager for the CCTB Day Treatment Program is Mr. David Villella

(343-5039).

I have reviewed the above information and consent to this referral being sent to the CCTB Intake for eligibility for the

Day Treatment Program. I agree to the exchange and release of information between the referring school board and

CCTB.

Authorized By:

Parent/Guardian (please print full name clearly)

__________________________________

__________________________________

Signature of Parent/Guardian

(required)

Signature of Child over the age of 12 years

Date:

Date:

_______________________________________

Signature of School Principal

Date:

SCHOOL HEALTH SUPPORT SERVICES – Referral Form

School Board School School

Phone / / School Address & Postal Code Teacher

Principal IPRC: □ Yes □ No

Student Name Gender: □ M □ F Grade: DOB: / / Day Month Year

Health Card Number Version Code

Physician:

Student lives with: ( ) mother ( ) father ( ) foster parent ( ) other:

Contact Person Relationship Address/Postal Code Home Phone # Daytime Contact #

1. _/ / _/

2. _/ _/ /_

Preferred Contact Person:

Guardian (if other than parent): Phone:

Address: Relationship to student:

List reason for referral and specific educational problem(s) encountered:

REQUIRED SCHOOL HEALTH SUPPORT SERVICE – Check Appropriate Space(s) Attach the appropriate therapy checklist/report to the referral form

( ) Speech Therapy ( ) Nursing

( ) Occupational Therapy ( ) Nutritional Counselling

( ) Physiotherapy

School Official Signature: Date:

SCHOOL HEALTH SUPPORT SERVICES

OCCUPATIONAL THERAPY TEACHER QUESTIONNAIRE

STUDENT: SCHOOL:

Grade: Age: Date Completed:

Completed by: (Name and Designation)

* Please ensure all areas of the Occupational Therapy Teacher Questionnaire are completed.

GENERAL GUIDELINES:

Students attending school full time who have difficulties in the areas of gross and/or fine motor skills that impact on their daily school performance may benefit from Occupational Therapy services from the Community Care Access Centre.

Students who present exclusively with non-motor difficulties, e.g., Visual Perceptual difficulties, Learning Disabilities, and/or Behaviour problems are not within the mandate of the Thunder Bay Community Care Access Centre for the provision of occupational therapy services.

A student who continues to struggle with written output following school intervention, such as the use of an appropriate hand writing program and sufficient practice opportunities, could be a candidate for an occupational therapy assessment. School personnel are asked to provide documentation about the effectiveness of the strategies that were tried and to enclose a sample of the student’s work following their intervention.

In the school setting, the occupational therapist works as a consultant, providing strategies and suggesting activities to accommodate or improve motor difficulties. Parents and school personnel will be expected to follow through with the activity suggestions provided by the occupational therapist.

Please confirm the following information about the student with parent/guardian:

The student is currently receiving occupational therapy from another source: ( ) Yes ( ) No If yes please contact the School Health Support Services Coordinator to discuss referral options prior to completing a referral.

The student received previous occupational therapy: ( ) Yes ( ) No If yes: Place/Date received: (A copy of the occupational therapy report is requested with the referral if therapy occurred within the last two years.)

Medical Diagnosis (if any):

The student has identified difficulties with vision: ( ) Yes ( ) No Comment:

If it is suspected that the student has difficulties with vision, it is recommended that this be discussed with the parent as a visual examination may be indicated.

Occupational Therapy Teacher Questionnaire

Student Name:


Other assessments completed: Educational Psychology Other

What are the school’s expectations/desired outcomes regarding occupational therapy for the student?

Comment on changes that have been made to support the student’s classroom/school environment or academic programming. Please specify in all areas that apply.

( ) Location (seating) in the classroom:

( ) Modifications to work expectations:

( ) Accommodations to work expectations:

( ) Educational Assistant support provided:

( ) Other educational support provided:

( ) Other:

GENERAL CLASSROOM PERFORMANCE The student:

TEACHER CCAC Use Only

ƒ Works up to grade level in all areas/subjects. Specify any weak areas:

Yes No N/A

ƒ Accurately discriminate colours, shapes, sizes, numbers and letters. Comments:

Yes No N/A

ƒ Easily copies from a far copy model (backboard). Yes No N/A ƒ Easily copies from a near copy model (from desk). Yes No N/A ƒ Demonstrates good organizational skills i.e. work and work

area is as organized as peers. Yes No N/A

ƒ Attends well to tasks. Comments:

Yes No N/A

ƒ Completes work at pace of the classroom. Comments:

Yes No N/A

ƒ Has no difficulty following verbal/visual instructions. Comments:

Yes No N/A

ƒ Constructs age appropriate puzzles. Yes No N/A ƒ Is a smooth reader (grade appropriate). Yes No N/A ƒ Draws basic shapes. Yes No N/A ƒ Draws a human figure in proportion. Yes No N/A ƒ Has a well-developed concept of left and right.


Student Name:


CLASSROOM PERFORMANCE (Written Work) The student:


ƒ Has legible printing. Yes No N/A ƒ Has legible handwriting. Yes No N/A ƒ Has legible printing/handwriting if takes enough time or if asked

to redo. Yes No N/A

ƒ Has good spacing between letters or words. Yes No N/A ƒ Has good letter formation: able to reproduce all letters/numbers

automatically for their grade level. Yes No N/A

ƒ Forms letters/numbers without reversals by age 8. Yes No N/A ƒ Prints/writes on the line. Yes No N/A ƒ Has been given a printing/writing program to work on beyond

what has been provided during regular classroom instruction. If Yes indicate the amount of time spent and describe outcome of intervention used to date:

If No or N/A please explain:

Please submit a sample of printed/written work.

Yes No N/A

FINE MOTOR The student:

ƒ Manipulates small objects adequately (buttons, beads, coins, blocks).

Yes No N/A

ƒ Does not have an awkward pencil grasp. Holds pencil properly. Yes No N/A ƒ Is definitely right or left handed by 7 years of age. Yes No N/A ƒ Applies adequate pencil pressure (not too dark or too light). Yes No N/A ƒ Manipulates scissors well for the student’s grade or age. Yes No N/A ƒ Uses both hands well together for bilateral tasks i.e. cutting,

stabilizing the paper while printing. Yes No N/A

ƒ Uses or has tried special tools. Circle or specify: pencil grips, adapted pencils or scissors, slanted writing surface, coloured paper or overlays. If No please explain:


Student Name:


GROSS MOTOR The student:


ƒ Participates without difficulty in physical education class, games and playground activities.

Yes No N/A

ƒ Participates in physical activity without tiring easily. Yes No N/A ƒ Has good balance and coordination. Yes No N/A ƒ Appears safe on stairs or on playground equipment. Yes No N/A ƒ Has proper standing/sitting posture. Yes No N/A ƒ Has a coordinated gait when walking or running. Yes No N/A ƒ Throws and catches a ball without difficulty. Yes No N/A ƒ Can imitate or sequence motor tasks without difficulty (i.e.

skipping, Simon Says, clapping games, rhythmic patterns). Yes No N/A

SENSORY The student:

ƒ Avoids light touch or contact. No Yes N/A ƒ Reacts inappropriately to touch (e.g. light pat on shoulder,

hand-over-hand assistance, crowded situations such as circle time or standing in line). Comments:

No Yes N/A

ƒ Avoids messy play. No Yes N/A ƒ Is irritated by certain clothing textures. No Yes N/A ƒ Is overly sensitive to loud or unexpected noises. No Yes N/A ƒ Has a tendency to be restless or fidgety. No Yes N/A ƒ Is overly sensitive to bright lights. No Yes N/A ƒ Interacts inappropriately with peers.

If Yes provide comments: No Yes N/A

BEHAVIOUR

The student has behaviour issues at school. If Yes describe behaviours:

No Yes

The student’s behaviour issues prevent adequate classroom productivity.

No Yes


Student Name:


ACTIVITIES OF DAILY LIVING

The student:

TEACHER

CCAC Use Only

ƒ Can dress independently for recess (age appropriate). Yes No ƒ Can manage fasteners, zippers, button, shoelaces. Yes No ƒ Feeds self independently. Yes No ƒ Eats adequately (no chewing, swallowing, choking concerns). Yes No ƒ Uses utensils well to eat/drink (container lids, spoon, knife,

straw, etc.). Yes No

ƒ Toilets self independently. Yes No ƒ Uses adapted equipment for any of the above activities

(utensils, toilet seat, bars, etc.). Specify: Yes No

Comments:

EQUIPMENT The student:

ƒ Presently has splints/brace for arm(s) or leg(s). Yes No N/A ƒ Presently has special equipment in classroom (seating,

computer, slant board). If Yes please specify:

ƒ Equipment meets needs of school environment. Yes No N/A ƒ Anticipated equipment needs.

Specify:

Yes No N/A

ƒ Safety concerns. If Yes please explain.

Yes No N/A

ADDITIONAL INFORMATION / COMMENTS:

Parent(s) and school personnel are expected to follow through with the programming suggestions provided by the occupational therapist. Please indicate who will participate in the follow-up.

Classroom Teacher Resource Teacher Educational Assistant Parent/Guardian

Other:

Sent: Received:

SOCIAL WORK/ATTENDANCE REFERRAL - ELEMENTARY Identifying Data:

School: Student Name:

Referral Source: Age: Birth Date

(Day/Month/Year):

Telephone: Grade:

Parent/Guardian Parent/Guardian

Parent Name: Parent Name:

Address: Address:

Telephone: Telephone:

Reason for Referral: Attendance Social skills Child Welfare Concerns

(printout attached YES NO ) Personal hygiene Inadequate Clothing & Nutrition

Drastic change in behaviour Self-esteem Family Issues

Classroom conduct Negative peer relations Crisis Intervention

Late/absent Substance abuse concerns Suicidal Ideation

Consistent incomplete school work Anxiety Self-Harm

School Performance Depression Grief

Bullying Psychosis Diagnosed Mental Health Issues

Poses Risk to Others in School Environment Trauma Undiagnosed Mental Health Issues

Victim of Sexual Assault Other (please explain):

Comments:

School Interventions: Assessments: Facilitator involvement Individual counselling Academic

Parental involvement Family counselling Learning

Timetable adjustment Group counselling Psychological

Program modifications Home Instruction Speech/Language

School day modified SALEP Application Exceptional

Psychological consult IPRC initial or review (please specify)

Attendance/Conduct monitoring Referral to Transitions Program

Active File with Attendance Counsellor Referral to Assessment & Consultation Class

Referral to School’s Alternative Ed Program Referral to Dilico Day Treatment Program

Referral to Alternative Program (name program): Referral to Child Welfare Agency (identify):

CAS Dilico Date:

Current Communtiy Service Providers: Probation CCTB Child Welfare Other:

Comments:

SOCIAL WORK/ATTENDANCE REFERRAL - ELEMENTARY Page 2

Has the Parent(s)/Guardian(s) been informed of this referral? YES NO

If NO, please explain:

Vice-Principal Comments & Recommendations:

Social Worker Signature: Vice-Principal Signature:

Sent: Received:

SOCIAL WORK/ATTENDANCE REFERRAL FORM - SECONDARY Identifying Data:

School: Student Name:

Referral Source: Age: Birth Date

(Day/Month/Year):

Telephone: Grade:

Parent/Guardian Parent/Guardian

Parent Name: Parent Name:

Address: Address:

Telephone: Telephone:

Reason for Referral:

Attendance Social skills Child Welfare Concerns

(printout attached: Yes No ) Personal hygiene Inadequate Clothing & Nutrition

Drastic change in behaviour Self-esteem Family Issues

Classroom conduct Negative peer relations Crisis Intervention

Late/absent Substance abuse concerns Suicidal Ideation

Consistent incomplete school work Anxiety Self-Harm

School Performance Depression Grief

Bullying Psychosis Diagnosed Mental Health Issues

Poses Risk to Others in School Environment Trauma Undiagnosed Mental Health Issues

Victim of Sexual Assault Other (please explain):

Homelessness

Comments:

School Interventions: Assessments:

Student Services involvement Individual counselling Academic

Parental involvement Family counselling Learning

Timetable adjustment Group counselling Psychological

Program modifications Home Instruction Speech/Language

School day reduction SALEP Application Exceptional

Psychological consult IPRC initial or review (please specify)

Attendance/Conduct monitoring Active File with Attendance Counsellor

Referral to School’s Alternative Ed Program Referral to Child Welfare Agency (identify):

Referral to Alternative Program (name program): CAS Dilico Date:

Current Communtiy Service Providers: Probation CCTB Child Welfare Other:

Comments:

SOCIAL WORK/ATTENDANCE REFERRAL FORM - SECONDARY Page 2

Has the Parent(s)/Guardian(s) been informed of this referral? YES NO

If NO, please explain:

Vice-Principal Comments & Recommendations:

Social Worker Signature: Vice-Principal Signature:

Parents and Staff should note that referrals to community agencies are frequently updated. Please go to the Staff Portal to

ensure use of the most recent form.

Please also note that School Based Health Services are in the midst of a significant change. Past forms have been left in this

plan for reference only and will be updated once changes have been finalized.