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Policy on Disruptive Social BehavioursPDF 29
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Policy on Disruptive Social Behaviours, Aitchison College
29
Annexe 5: Referral to the Psychologist Form
Student's Name: __________________________________________ House: __________________________
Class & Section: ________________________________ Date of Referral: ___________________________
Reason for Referral
_________________________________________________________________________________________
_________________________________________________________________________________________
Incident Summary (Attach detailed incident summary if available or use the space below)
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________
Additional Remarks
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________
Confidentiality and Consent
Parent/Guardian Consent Obtained*: Yes/ No
Date: _________________________
Via telephone by: _________________________ Name of Parent: __________________________________
Signature of Parent/Guardian: _________________________________ Date: ________________________
*Aitchison College reserves the right to refer a student to the psychologist for his benefit in serious instances
if the college is unable to reach the parents via telephone/ email.
Psychologist’s Section
Received by Psychologist:
Name: ___________________________________ Signature: _______________
Date: ___________ Time: ___________
Feedback from Psychologist:
Observations:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________