SCHOOL REFERRAL FORM

Full Name of Primary Parent / Guardian who has custodial responsibility for the referred student:
Parent / Guardian Email
example@example.com
Parent / Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is the Parent/Guardian aware of and supportive of the referral?

Other
Who is financially responsible for the cost of the services for which the student is being referred?

School Referral Steps

Once a school referral is received the following steps will be taken:
1. The parent / legal guardian will be contacted within 48 hours and asked to complete a Child Intake form.

2. Upon receipt of a Child Intake Form a parent intake appointment will be scheduled dependent on availability and nature of service required.

3. At time of intake parents will be asked to sign a Release of Information (ROI) providing The Wellness Centre with permission to obtain and share information with the referring school.

4. The referring school will be updated on the status.

Referrant Signature
I, First Name* Last Name* agree all information provided is factual to the best of my ability.
Date

MonthDayYear
Date
Should be Empty:

School Referral Form