Form 210-7
Referral To Student Support Services Parent/Guardian Information
/ Insert School Name,
Address, Town, Sask., Postal Code
Phone: (Number) Fax: (Number)
email address if applicable / Reference / AP 210 Services for Students with Diverse Needs
Revised / February 5, 2018
Level / School
Submit to / Student Support Teacher
When / As Required

Service Sought (Select One Only):

Psycho-educational Assessment / Speech-Language / OT / PT

Student Information

Student Name / Grade
Date of Birth (mm/dd/yyyy) / Age
Custodial Mother’s Name
Custodial Mother’s Address
Custodial Mother’s Home Phone / Custodial Mother’s Cell Phone
Custodial Mother’s Work Phone / Custodial Mother’s Email
Custodial Father’s Name
Custodial Father’s Address
Custodial Father’s Home Phone / Custodial Father’s Cell Phone
Custodial Father’s Work Phone / Custodial Father’s Email
Custodial Guardian’s Name
Custodial Guardian’s Address
Custodial Guardian’s Home Phone / Custodial Guardian’s Cell Phone
Custodial Guardian’s Work Phone / Custodial Guardian’s Email
Classroom Teacher
Resource Teacher (if applicable)
Principal / Referral Date

Family Information

Names and Ages of Siblings
Language Spoken at Home

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Parent Information

Areas of Concern (Check all that apply)

Reading Achievement / Fluency (Stuttering) / Expressive Grammar
Concentration / Following Directions / Voice
Math Achievement / Written Language / Articulation
Attention / Cognitive Development / Other:
Behaviour / Self-regulation
Fine Motor Skills / Memory
Social/Emotional Development / Sensory Processing
Gross Motor Skills / Health
Sentence Construction / Adaptation to Environment
Expressive Vocabulary / Motivation

Rate the Impact of the Primary Area of Concern at Home

1 / 2 / 3 / 4 / 5
Mild Impact / Moderate Impact (Manageable but requires intervention) / Significant Impact

Medical & Other Services

Last Vision Examination / Date (mm/dd/yyyy)
Results:
Last Audiology Examination / Date (mm/dd/yyyy)
Results:
Has your child had ear tubes?
Yes / No / Date (Month/Day/Year)
Has your child had ear infections?
Yes / No / Date (Month/Day/Year)

Involvement with Outside Agencies

Kinsmen Children’s Centre / Community Living Division
Child Psychiatry / Social Services
Private Counselling Services
Heartland Health Children Services: ______
Heartland Health Addictions Services: ______
Other: ______

Please Check Any Relevant Items

Social skills / Family problems
Social/Emotional development / Anxiety
Disruptive behavior / Anger management
Victim of bullying / Bullying behaviour
Learning problems / Excessive sadness
Withdrawal / Excessive worry
Recent loss / Social neglect
Aggressive / Sleeping problems
Eating problems / Head injury
Mood swings / Seizures
Asthma / Drug/Alcohol use
Lethargic
General Allergies: List______
Food allergies: List ______
Ongoing medication: List ______
Other: ______
Diagnosis (if any) (e.g. Autism, Down Syndrome):
When diagnosed:
Where diagnosed:

Parent/Guardian Information

Name some things your child does well (ie. school work, hobbies, extra-curricular, sports):

What difficulties is your child experiencing at home and at school?

How have you been assisting your child with these difficulties?

What changes would you suggest to make things better for your child?

Parent/Guardian Consent

As the parent/guardian of this child, I grant permission for Sun West School Division Student Support Services to conduct an assessment, programming, and/or follow up. I understand that I have a right to be fully informed regarding the results of this assessment and that the information gained will be used in developing an appropriate educational plan for my child. I also understand that the results will be shared with school personnel who are involved in instruction and programming for my child.

______

Parent/Guardian’s SignatureDate

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