Health and Wellness Program Referral Form

* required field

*Teacher's name		Female Male Trans Gender non-conforming Prefer not to disclose Self-defined (please specify below)
Email
*Date of birth	(yyyy/mm/dd)
Address
City
Postal code
*Home phone
School phone		Member ID
School name		No. of sick days remaining
*School district
*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