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Health & Wellness Program
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
(Select)
N/A
5 Southeast Kootenay
6 Rocky Mountain
8 Kootenay Lake
10 Arrow Lakes
19 Revelstoke
20 Kootenay-Columbia
22 Vernon
23 Central Okanagan
27 Cariboo-Chilcotin
28 Quesnel
33 Chilliwack
34 Abbotsford
35 Langley
36 Surrey
37 Delta
38 Richmond
39 Vancouver
40 New Westminster
41 Burnaby
42 Maple Ridge
43 Coquitlam
44 North Vancouver
45 West Vancouver
46 Sunshine Coast
47 Powell River
48 Howe Sound
49 Central Coast
50 Haida Gwaii/Queen Charlotte
51 Boundary
52 Prince Rupert
53 Okanagan Similkameen
54 Bulkley Valley
57 Prince George
58 Nicola Similkameen
59 Peace River South
60 Peace River North
61 Greater Victoria
62 Sooke
63 Saanich
64 Gulf Islands
67 Okanagan Skaha
68 Nanaimo
69 Qualicum
70 Alberni
71 Comox Valley
72 Campbell River
73 Kamloops-Thompson
74 Gold Trail
75 Mission
78 Fraser-Cascade
79 Cowichan Valley
81 Fort Nelson
82 Coast Mountains
83 North Okanagan-Shuswap
84 Vancouver Island West
85 Vancouver Island North
87 Stikine
91 Nechako Lakes
92 Nisga a
93 Conseil scolaire francophone
*
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
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