B You School Referral Form B You School Referral Form This form is for education professionals only. Please note that information on this form is kept confidential in accordance to Big Brothers Big Sisters' National Confidentiality Policy signed by all staff and volunteers. Today's Date MM slash DD slash YYYY Student's Name* First Last Student's Current Grade5678Referral form completed by:* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. Last Referrer's Email* Please share some of this student's strengths.Please describe why this student could benefit from being a part of Go Girls.*School/Academic AchievementPlease check all risks/needs that apply to this student. Poor attendance Lack of class participation Disruptive behaviour in school Struggling academically Gives up easily/ low academic confidence Learning disabilities (suspected or confirmed) Attention difficulties ADHD/ADD diagnosis (suspected or confirmed) Fetal Alcohol Spectrum Disorder (suspected or confirmed) Language barrier or ESL (English as second language) Difficulty with authority Suspensions from school Overachiever - high academic pressure Family SituationPlease check all risks/needs that apply to this student. Single parent family Blended family (Step-parents) Transient family (suspected or confirmed) Living in Subsidized Housing Low income family (suspected or confirmed) Foster home/ Child is in Ministry's care Refugee family Adopted Separated from siblings Sibling(s) with high needs Conflict/violence in family (suspected or confirmed) Alcohol/drug abuse in family (suspected or confirmed) May have experienced abuse (suspected or confirmed) Chronic illness in family Depression/Mental Illness in family (suspected or confirmed) Death in family/ History of loss Parent with no contact Social/Emotional DevelopmentPlease check all needs/risks which apply to this student. Difficulty relating to peers Loneliness/social isolation Emotional coping difficulties Low communication skills Low interest in activities/self-inclusion Difficult to engage Negative peer group Bullying other children Being bullied Anxiety Low self-confidence Low self-compassion (hard on themselves) Questioning sexual identity Questioning gender identity Poor body image Depression Current or past eating disorder Issues around weight/eating Self-mutilation (cutting) Trichotillomania (hair pulling) Suicide ideation/attempts Other mental health concerns Other Relevant InformationAnything else we should know that will help us serve this student better in our programs? Please contact Kait Burns at kait.burns@bigbrothersbigsisters.ca if you have any questions.
