School Report Form

SCHOOL REPORT FORM
(CONFIDENTIAL)

To: Teacher and/or Principal,

This child has been referred to Paediatric Psychiatry. Parents have given permission for us to contact you. It would be extremely beneficial to our assessment if the following form could be completed. Please fax this confidential form to the above address. This information is essential to our assessment and may be incorporated in our feedback to the family. Thank you for your assistance.


Person Filling Out Form


Name
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Relationship to Student
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Student Information


Child's Name
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Grade Placement
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Teacher
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School Principal
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School Name
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School Address
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Postal Code
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School Phone Number
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School Fax Number
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1. GENERAL APPROACH TO SCHOOL: (Willingness or not to take part in things, lateness or non-attendance, activity level, attitudes towards work)
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2. HOW DOES CHILD GET ALONG WITH OTHER CHILDREN? (Shy, outgoing, liked by peers, isolated from peers, change in relationships etc)
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3. HOW DOES CHILD GET ALONG WITH TEACHER(s)? (Cooperative, belligerent, timid, change in relationships, etc.)
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4. WHAT DO YOU SEE AS THIS CHILD'S PROBLEM AT SCHOOL? (if any)
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5. HOW HAVE YOU APPROACHED THESE PROBLEMS? (list resource time, resource teacher and specific programming)
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6. ANY RELEVANT INFORMATION ABOUT HOME BACKGROUND and PARENT CHILD RELATIONSHIP?
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7. ADDITIONAL COMMENTS AND REMARKS.
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8. SPECIFIC TEST RESULTS:

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Specific Test Results Other
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* If you need to obtain specific consent before results can be released, please do so.
Once all reports have been received, the student’s name will be added to our waiting list.

9. SCHOOL PERFORMANCE: (Is this child in a regular or modified program?
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Reading
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Spelling
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Arithmetic
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Written Language
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Social Skills (caring, cooperating, etc.)
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Musical/Artistic Skills
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Physical skills/Motor coordination
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Contact Us

Contact us today, appointments by referral only.

Phone: (306) 954-3411
Email: office@hopeclinicon5th.ca

Open Monday to Thursday
9am to 4:30pm

For Emergency Situations

Please go to the Royal University Hospital (RUH) 

Or call the local Crisis center at(306) 933-6200