Health and Wellness Program Referral

Teacher's full name*

Select a choice

Female
Male
Trans
Gender non-conforming
Prefer not to disclose
Self-defined (please specify below)

No. of sick days remaining

Teacher's email

Date of birth

(yyyy/mm/dd)

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 their allocated hours for four consecutive weeks.
This teacher is using sick days to manage their 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)

Health and Wellness Program Referral Form

Referral source