Referral for Well-being Supports 2020-2022

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This form is to be completed if seeking support from a mental health professional from the St. Clair Catholic School Board. It is only for families that are part of the school board.All personal information, provided within this form, will be kept strictly confidential and will only be provided to the mental health lead and mental health professional providing services. It will not be shared with any person or group that is not associated with this work.

Name *

Provide email address *

Provide text number *

What school does your child attend? *

What supports are you seeking? *

Is the support for you or someone else? Please explain. *

When is a good time to contact you? Days of the week and times *

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