School Intake Form

1
School Name* This field is required.
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Referring Teacher's Full Name* This field is required.
First Name
Last Name
4
Teacher Type
Please Select
Please Select
Classroom Teacher
CRT
Specialist Teacher
Assistant Principal
School Principal
Well-Being
Other
5
Phone Number
Area Code
Phone Number
6
Email* This field is required.
example@example.com
7
Name* This field is required.
First Name
Last Name
8
Grade* This field is required.
9
Date of Birth* This field is required.
Date
Day
Month
Year
10
Please list in order of whom to contact first* This field is required.
11
Tick all that apply:* This field is required.
Academic difficulties
Behavioural challenges
Social communication
Emotional/mood concerns
Other
12
Provide a more comprehensive explanation of the concerns noted above. Attach additional sheets if necessary.
13
Have any interventions or treatments been tried with the student? If so, please describe.
14
What are some of the student's strengths or areas they excel in?
15
Mathematics
Please Select
Please Select
At standard
Below standard
Above standard
16
Reading
Please Select
Please Select
At standard
Below standard
Above standard
17
Reading Comprehension
Please Select
Please Select
At standard
Below standard
Above standard
18
Written Expression
Please Select
Please Select
At standard
Below standard
Above standard
19
Oral Language/Expression
Please Select
Please Select
At standard
Below standard
Above standard
20
Has the student repeated any grades?
Yes
No
Unsure
21
Has the student received special education services?
Yes, currently
Not currently but in the past
Never received
Unsure
22
If you replied "yes" or "not currently but in the past" to the previous question, please describe
23
Student has an IEP?
Yes
No
24
Please attach any relevant documents, such as report cards, previous assessment reports, or IEPs
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25
By completing and signing this referral form, I confirm that the student's parent/guardian has been informed of and has given consent for this comprehensive assessment.
26
Signature of Referring Teacher
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27
Date
Date
Day
Month
Year
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