In-School Mentoring Student Referral Form - PDSB & DPCDSB - Big Brothers Big Sisters of Peel York

This form will take you between 10-15 minutes to complete and is meant for school staff to fill out. The information provided shall be kept in confidence and will only be used for the purpose of matching the student with a volunteer in our agency. Please ensure all information is complete before submitting. Incomplete referrals cannot be processed.

Child's Information

Child's Name*

First Last

Date of Birth*

Gender Identity*

Grade*

Teacher*

School*

Match Goals

Please check the FIVE main match goals you have for this student.*

Build self-esteem, self confidence

Develop / learn skills (sports, activity, life skills, etc.)

Enhance academic success

Enhance social relationships and social skills

Develop friendships with peers

Problem-solving skills

Learn respect for others / improve behaviour

Anger management / impulse control

Have fun

Please assess the student in all of the areas listed below using the following scale:

1 = Major Concern
2 = Below Average
3 = Average
4 = Above Average
5 = Exceptional

Build self-esteem, self confidence*

Develop / learn skills (sports, activity, life skills, etc.)*

Enhance academic success*

Enhance social relationships and social skills*

Develop friendships with peers*

Problem-solving skills*

Learn respect for others / improve behaviour*

Anger management / impulse control*

Have fun*

Reason for Referral

Why are you referring this student to the ISM program?*

Family Constellation

Please confirm the people living with this student and any custody arrangements:*

What is this student's relationship with their family members like?*

Describe the Student

Please check the items relevant to the student in each area below:

Personality:*

Shy/Quiet - Introvert

Outgoing - Extrovert

Imaginative/Dreamy

Sad

Happy

Please comment:*

Behaviour:*

Please comment:*

Social Skills:*

Fights with peers

Social anxiety (shy/afraid to be around others)

Has few/no friends

Works well in groups

Works well 1:1

Works well with adults

Shows empathy to others

Please comment:*

Academics:*

Absenteeism

Frequent detention

Poor grades

Incomplete homework

Doesn't complete tasks

Can follow instructions/directions

Participates well in class discussions

Likes routine

Takes risks

Learning Styles:*

Visual

Auditory

Kinesthetic

Verbal

Logical

Solitary

Social

Please comment:*

Is this student functioning at grade level?*

Yes

If No, please explain.

Has this student been diagnosed with an exceptionality? (ex. ADHD, Learning Disbaility, ASD)*

Yes

If Yes, please explain.

Is this student receiving ISSP or Special Education support services?*

Yes

If Yes, for what areas?

Please list the student's strengths and interests:*

Additional Comments

Please list any other pertinent information regarding this student.*

Medical Concerns

Please list any allergies, medications, etc. that the Mentor should be aware of.*

Availability for Visits

Which days/times would work best for your student to meet with a Mentor?*

Approval of Referral

Signature:*

Your Role (ex. Principal, CYW, Teacher, Social Worker, SERT):*

Phone

This field is for validation purposes and should be left unchanged.

In-School Mentoring Student Referral Form – PDSB & DPCDSB

ISM Student Referral Form - PDSB & DPCDSB

Child's Information

Match Goals

Reason for Referral

Family Constellation

Describe the Student

Additional Comments

Medical Concerns

Availability for Visits

Approval of Referral