FNESC/FNSA SEP REFERRAL FORM
For Psycho-educational Assessments
Student’s Name: _____________________________ Date of birth: __________________
Parents/Guardians: ________________________________ Telephone: ____________________
Address: ______________________________________________________________________
Date of last Psychological/Psychometric Assessment: __________________________________
Classroom Teacher: _______________________Current Grade:____ Type of class: __________
Reason for Referral: What are the major concerns, questions about this child?
______________________________________________________________________________
______________________________________________________________________________
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How long and how often has this student been having these difficulties?
______________________________________________________________________________
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Describe the child's present placement, and any special remediation or other help given
previously and/or presently.
______________________________________________________________________________
______________________________________________________________________________
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Briefly describe the student’s personal characteristics, health or home background:
______________________________________________________________________________
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Describe the child’s behaviour:
______________________________________________________________________________
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Describe the child's learning: (activity level, attention, organization, impulsiveness)
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What has this child’s attendance been like over the past few years? (approx.%)
______________________________________________________________________________
Describe the child’s academic development/performance:
______________________________________________________________________________
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Compare the child's fine and gross motor skills to his/her peers:
______________________________________________________________________________
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Compare the child's speech and language skills to his/her peers:
______________________________________________________________________________
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Does the child have special interests or talents?
______________________________________________________________________________
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Describe his/her social behaviour with adults and with other children:
______________________________________________________________________________
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Parent/School relationship: (Are parents involved, concerned, aware of difficulties?)
______________________________________________________________________________
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List current school team personnel, and their involvement:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Any Medical conditions:
______________________________________________________________________________
________________________________________________________________________
Additional Comments:
______________________________________________________________________________
______________________________________________________________________________
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Please attach reports of any previous testing (e.g., Psychological/Psychometric, SpeechLanguage, Vision, Hearing, Achievement/Academic, Occupational Therapy)
Thank you for your caring support for this student!
Parental Authorization for Psychological Assessment
& Disclosure of Information
After consideration by the school team and in consultation with you, it has been determined that
a psycho-educational assessment would be beneficial in supporting your child
______________________________________ at _______________________________ School.
Purpose of Assessment
The main purpose of the assessment is to help the teachers and parents to best support the student
in school.
Assessment Process
The psycho-educational assessment may include:
 Information from parent or guardian.
 Observations conducted by school personnel on ability, achievement, behaviour and
attendance.
 Testing by a qualified school psychologist, which may include measures of: Intellectual
Ability, School Achievement, Perceptual Abilities, Adaptive Functioning (i.e., life skills),
Behaviour (i.e., attention, self-concept, social and/or emotional functioning)
If you have any questions about the psycho-educational assessment, you may contact Dr.
Leonard Stanley, Coordinator at 250 752-5423 or email - lenkz@shaw.ca
Outcomes
Following the assessment, the psychologist will discuss the findings and recommendations with
the parents and relevant school staff. The psychologist will write a report, and copies will be
provided to the parents/guardians and the student's school file.
For some students, assessment findings may assist in identifying various learning difficulties as
referenced in the B.C. Ministry of Education guidelines and/or in the Diagnostic and Statistical
Manual of Mental Disorders - Fourth Edition. If a student meets criteria as a student having
special needs, additional services may be recommended.
Voluntary Consent
1. Consent for Referral - The school would like your consent to refer your child for
assessment to FNESC – Special Education. The FNESC special education team will
determine if this referral will be included among the limited number of assessments available
to the schools of the province.
2. Consent for Assessment - If your child is selected for assessment, the school would also like
your consent for the assessment itself. Dr. Leonard Stanley, along with his psychology team
will coordinate the assessment with the school and FNESC.
If your child is not selected by FNESC for assessment during this upcoming school year, the
consent must be renewed for any future referral in the future. Authorization and participation in
the psychological assessment are voluntary.
Right to Withdraw
The parent/guardian/independent student will be notified in advance when the assessment is to
take place and they may revoke this consent at any time by notifying the principal of the child’s
school.
Confidentiality
Information will be strictly confidential. Results will be used in the school only by those
responsible for developing a support program for your child. The psychologist will keep a
confidential copy of your child’s results.
CONSENT
I hereby consent to have my child, ______________________________________,
Please check boxes to indicate your consent for the following:
REFERRED FOR POSSIBLE ASSESSMENT - I understand that the FNESC/FNSA
special education team will examine information to determine if my child should be assessed
during the upcoming school year, but that they may not select my child for assessment this
school year.
CONSENT FOR ASSESSMENT - If my child is selected, I hereby consent to have my
child participate in a Psycho-educational Assessment by a FNESC approved psychologist as
described above.
AUTHORIZATION SIGNATURES
__________________________
Name of Principal or Designate
__________________________
Name of Parent/Guardian/
Independent Student
___________
Date
(mm/dd/year)
___________
Date
(mm/dd/year)
______________________________
Signature of Principal or Designate
______________________________
Signature of Parent/Guardian/
Independent Student