• STUDENT REGISTRATION FORM

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Before arranging an intake interview, please complete/obtain all of the following:

• School District Registration Form (attached)
• Family/School/Community Referral Form (attached)
• Copy of Last Report Card (Please obtain from last school attended)
• Copy of Last Individual Education Plan - I.E.P. (Please obtain from last school attended)

Upon completing the above check-list, please contact Mitch Quinn (School Coordinator)
at 604-856-9192 to arrange an intake interview.

Family/School/Community Referral Form

Application Date: _____________________

Student’s Name: __________________________________

Referred by:    Family 0   School 0   Community 0   Probation 0

Name of Referring Person _______________________________ Phone:____________

Reason for Referral:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

COMMUNITY SUPPORTS:

Social Worker ______________________________________________ Phone:______________________

Community Support Worker ___________________________________ Phone:______________________

Probation Officer ____________________________________________ Phone:______________________

Mental Health Worker ________________________________________ Phone:______________________

Alcohol and Drug Counselor ___________________________________ Phone:______________________

Aboriginal Worker ___________________________________________ Phone:______________________

Psychiatrist ________________________________________________ Phone:______________________

Psychologist _______________________________________________ Phone:______________________

Forensics _________________________________________________ Phone:_______________________

ACADEMIC SUPPORTS:

Educational Psychologist _____________________________________ Phone:_______________________

School Based Team Member __________________________________ Phone:_______________________

Learning/Resource Teacher ___________________________________ Phone:_______________________

Tutorial Services Used _______________________________________ Phone:_______________________

Other Educational Supports ___________________________________ Phone:_______________________

By signing and completing this form, I give Mitch Quinn consent to contact the support persons and agencies listed to obtain information deemed relevant in order to develop an effective therapeutic and academic plan. I understand that whatever information is discussed will be kept confidential within the Apex Secondary support team.

Guardian Signature: ________________________________ Date: _________________

STUDENT RESPONSE (to be completed in student’s own handwriting):

Why do you think that you are being referred to Apex Secondary?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Student’s Signature: ___________________________________ Date: __________________