Project Resiliency Adult Referral Form

Referring school staff/SLO name and position*

First Last

Current School*

Student Being Referred*

First Last

Date of Birth (Month - Day - Year)*

Current Grade*

Is the student designated? If so, please list below:

Aboriginal Ancestry?

Parent/Guardian's Name*

First Last

Parent/Guardian's Phone*

Please list the adults who are supporting/connected to this student*

Have you notified the student's school counsellor about this referral?

I am referring this student to:*

Key Safety Information

Past or current harm to self, suicidal ideation, attempts, extreme high risk behaviour, etc (provide info below)
Past or current harm/threats to others (provide info below)
History of weapons (provide info below)
Concerns about substance use/misuse (provide info below)
Requesting Administrator phone call prior to enrolment
VTRA in process or past VTRA

Any Additional Information (e.g designation, pertinent IEP info, triggers, diagnosis etc)

Does this student have?

Phone

This field is for validation purposes and should be left unchanged.

Disclaimer