Health and Wellness Program Referral Form

* required field

*Teacher's name:		Female Male
Email:
Address:		*Date of birth (yyyy/mm/dd):
City:		Postal code:
*Home phone:		School phone:
School name:		Member ID:
*School district:		Number of sick days remaining:
*Contract %:	% working in current year:
Diagnosis (optional):
*Reason for referral (select one): This full-time teacher has been absent from work for 20 consecutive working days This part-time teacher has not worked his/her allocated hours for four consecutive weeks. This teacher is using sick days to manage his/her symptoms. (Non-consecutive use of sick leave--approximately 10 days in the current school year and 10 days in each of the past two years.) Other (please specify below). Other reason:

Referral source

Date:
*Name:		GWL Local School district Self
Position:
*Phone:	Ext.:
Comments:
Local has discussed program with teacher? Yes No