Confidential

KITSILANO SCHOOL BASED TEAM REFERRAL

*Please attach most recent report card to referral form.*

Student Name: Date Referred:

Counsellor: Student #
Referring Teacher: D.O.B.
Ministry Designation: First language:
Previous assessments Relevant medical info/outside agencies:
(Type, Date):
Current program: Previous school(s):

1. Have you contacted the parent/guardian? Yes No

2. Classroom Observations
Observation 1:
Date: _____________________ Time: _________________ Class: _____________________
Observation: _______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Observation 2:
Date: _____________________ Time: _________________ Class: _____________________
Observation: _______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

3. The purpose of this referral is: (please check off all applicable topics)
Attendance Concerns
punctuality day to day attendance
Comments: _______________________________________________________________________
__________________________________________________________________________________
Learning Concerns
organization class/time management
computation skills problem solving skills
speaking writing
listening reading
homework completion prerequisite skills
test/quiz results comprehension of major concepts
Comments: _______________________________________________________________________
_________________________________________________________________________________
 Behaviour Concerns
response to assistance engagement
confidence peer interaction
group activities attention to instructions
ability to focus
Comments: _______________________________________________________________________
_________________________________________________________________________________

Emotional/Mental Health Concerns

Comments: _______________________________________________________________________
_________________________________________________________________________________

Other (provide details) _________________________________________________________________

_________________________________________________________________________________

3. What outcome(s) do you expect from the School Based Team meeting?
____________________________________________________________________________________
____________________________________________________________________________________

4. Action (include personnel to carry out)

District testing _______________________
School-based testing __________________
No testing required
Program review (ESL/FI/HT) __________________
Apply for district program ___________________
Consultation ____________________