REFERRAL TO SCHOOL - BASED TEAM (SBT) Date: ___________

Student Name: _____________________ DOB: ___________ M / F

Course of concern: __________________ Grade: ____ IEP: Yes/No

Referred by: _______________________

Area(s) of Concern: Actions Taken by teacher:

___ Talked to parents

_____ Academic ___ Consulted with student’s other teachers
_____ Behaviour ___ Consulted with counsellor
_____ Attendance ___ Consulted with vice principal/principal
_____ Health/Safety ___ Consulted with IS case manager
_____ Other ____________________ ___ Reviewed student file
___ Other ___________________________

Pertinent information from student file:

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What strategies have you employed to assist the student with his/her difficulties?
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Other relevant information:

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 Reason for referral:
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Please return form to counsellor’s box.

Natalie Handy (A-D) Dan Taft (L-P)

Ettie Catto (E-K) Hilde Plotnikoff (Q-Z)

COUNSELLOR/CASE MANAGER REVIEW

FILE REVIEW:
___ Integration Support? Assessment(s)
___ Behaviour Support? ___ WJIII? Date(s): _____________
___ Discipline? ___ Psych Ed? Date(s): _____________
___ First Nations? ___ Other __________________________
___ Social Work?
___ Mental Health?
___ Other ___________

Comments:
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