Health and Wellness Program Referral

Teacher's full name*

Select a choice

Female
Male
Trans
Gender non-conforming
Prefer not to disclose
Self-defined (please specify below)

No. of sick days remaining

Teacher's email

Date of birth

(yyyy/mm/dd)

Contract %

% working in current year

Diagnosis (optional)

Reason for referral (select one)

This full-time teacher has been absent from work for 20 consecutive working days
This part-time teacher has not worked his/her allocated hours for four consecutive weeks.
This teacher is using sick days to manage his/her symptoms. (Non-consecutive use of sick leave--approximately 10 days in the current school year and 10 days in each of the past two years.)
Other (please specify below)

Health and Wellness Program Referral Form

Referral source