Document page
Policy on Disruptive Social BehaviourPDF 25
37 pagesrevision 47076
PDF 25
Page image rendered from the stored file at 110 dpi; it sharpens as you zoom. Outlines are placed from each region’s stored position on the page (612 × 792 pt).
readable
Source of this text: embedded text layer. The better of the embedded text and OCR is kept.
Annexe 3: 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:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Policy on Disruptive Social Behaviours, Aitchison College
25