Form 353-5
Student Support Services
Individual Counselling Program Plan
Insert School Name,
Address, Town, Sask., Postal Code
Phone: (Number) Fax: (Number)
email address if applicable
Reference
AP 353 Referral for Counselling
Services
Revised
July 29, 2013
Level
School
Submit to
School Counsellor
When
As Required
Student Name
Grade
Date of Birth (mm/dd/yyyy)
Age
Parents/Guardian Name
Address
Phone Number (Home)
Cell Phone
Phone Number (Work)
Email
School Name
Classroom Teacher
Student Support Teacher
(if applicable)
Principal
Referral Date
Family Information
Number of Older Siblings
Number of Younger Siblings
Custodial Parents
Birth Mother
Step-Mother
Birth Father
Step-Father
(if applicable)
(if applicable)
Areas of Concern
social skills
social/emotional development
disruptive behavior
victim of bullying
learning problems
withdrawal
recent loss
aggressive
rejection by peers
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mood swings
family problems
anxiety
anger management
bullying behavior
excessive sadness
excessive worry
social neglect
other
Primary area of concern at school:
Rate the impact of the primary area of concern at school:
1
2
3
Moderate Impact
4
(Manageable but
requires intervention)
Mild Impact
5
Significant Impact
Primary area of concern at home:
Rate the impact of the primary area of concern at home:
1
2
Mild Impact
3
Moderate Impact
4
(Manageable but
requires intervention)
Significant Impact
Counselling Goals
1.
2.
3.
Counselling Strategies/Programs
1.
2.
3.
Session 1
Case Notes/Progress
Date
Homework for Next
Session
Session 2
Case Notes/Progress
Homework for Next
Session
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5
Date
Session 3
Case Notes/Progress
Date
Homework for Next
Session
Session 4
Case Notes/Progress
Date
Homework for Next
Session
Session 5
Case Notes/Progress
Date
Homework for Next
Session
Session 6
Case Notes/Progress
Date
Homework for Next
Session
Session 7
Case Notes/Progress
Homework for Next
Session
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Date
Session 8
Case Notes/Progress
Date
Homework for Next
Session
Session 9
Case Notes/Progress
Date
Homework for Next
Session
Session 10
Case Notes/Progress
Date
Homework for Next
Session
Session 11
Case Notes/Progress
Date
Homework for Next
Session
Session 12
Case Notes/Progress
Homework for Next
Session
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Date
Discharge
Reason for Discharge
Date
Conditions (if any):
Date of Consultation with Parents (mm/dd/yyyy)
Date of Consultation with Principal/Teacher (mm/dd/yyyy)
Counsellor’s Signature
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Date