ISM Student Referral Form - YRDSB & SCDSB

"*" indicates required fields

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*
MM slash DD slash YYYY

Match Goals

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

Reason for Referral

Family Constellation

Describe the Student

Please check the items relevant to the student in each area below:
Personality:*
Behaviour:*
Social Skills:*
Academics:*
Learning Styles:*
Is this student functioning at grade level?*
Has this student been diagnosed with an exceptionality? (ex. ADHD, Learning Disbaility, ASD)*
Is this student receiving ISSP or Special Education support services?*

Additional Comments

Medical Concerns

Availability for Visits

Approval of Referral

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