Public Social Work Referral Form

Referral Date

Date

Student's Name*

First NameLast Name

Grade Level*

Classroom Teacher's Name

Additonal Siblings that attend SCCS? (Please list names and grades)

Referral Source *

ParentPeer/FriendExternal AgencyOther

External Agency Referral? Please state the organization.

Referer's Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Phone Number

Area CodePhone Number

E-mail*

Best time to contact *

Reason for the Referral*

Please provide further detailed information regarding this referral:*

Desired wellbeing outcome:*

Special Education Services

Please upload any paperwork relevant to this referral

Upload a File

Are any other services/organizations involved with this child or family? (Ex. Department of Social Services (DSS) involvement) *

Have the parents/guardians been notified of the referral?*

YesNoUnsure

Type a question

Privacy and Confidentiality Disclosure

All information shared with the SCCS School Counselor is confidential, meaning the child and families information will not be shared with a third party without prior parental consent. There are however limits to confidentiality.

These limits to confidentiality include:

- School Counselor's like other Department of Education (DOE) staff, have certain duty of care obligations to all students. The School Counselor is a mandatory reporter of child abuse and neglect. As specified under Part 5.1 A of the Care and Protection of Children Act 2007.

- If the School Counselor forms reasonable belief that the student is at risk of harm to themselves or others they have a duty of care to report this to a mental health service or to the police.

- If it is disclosed to the School Counselor that the student has engaged in a crime or is going to become involved in such an activity, the School Counselor will need to contact the Police.

Please note: We will always consult with parents prior to any information being shared with a third party such as an external agency or other SCCS staff. We will only share information with a third party if it is in your child's best interest.

School Counselor's are required to keep a file for each student accessing the SCCS Student Support Team. These files are kept on a secure database.

If you have any questions in relation to Privacy or Confidentiality, please contact a member of the SCCS Student Support Team at 704-509-5470.

I agree to Sugar Creek Charter Schools Privacy and Confidentiality Disclosure*

SCCS Social Work Support Referral Form