REQUEST FOR SERVICE

TYPE OF SUPPORT REQUESTED: DATE:

PLEASE CHECK:
☐Professional Learning ☐Classroom Observation ☐ Problem Solving ☐ ESS / Other Team Meeting
☐Co-facilitation of whole class or small group intervention ☐ Consultation ☐ Child & Youth Team (C&Y Team)
☐Request for SIW – Temporary Assignment Dates: _________ to ___________ ☐ Other:

FOR INDIVIDUAL STUDENT REQUESTS PLEASE COMPLETE THE FOLLOWING:

Student: Age: DOB:
Classroom Teacher: Referring Teacher:
Resource Teacher: Guidance Teacher:
School: Grade: Date of Request:
Parent(s) / Guardian(s):
Address:
Phone (H): (W):
Program: ☐English ☐ Early Immersion ☐Late Immersion
PLEASE CHECK AREA OF CONCERN:
☐ Academic ☐Social ☐Emotional Health ☐Speech / Language ☐Behavior ☐Motor Skills
Please describe area of concern:

Do the student’s parents share your concerns? ☐Yes ☐ No Please elaborate:

CURRENT SUPPORT (Please ensure that any documentation has been uploaded to the student’s electronic file.)
Please check (include name):
☐ EST-Resource: ______________ ☐SLP: _____________
☐EST-Guidance: ______________ ☐Educational Assistant ☐ Full time ☐ Part time
☐SIW: ______________ ☐District Lead: ______________
Other services/agencies involved with student (include name, if known):
Extramural: ☐Child and Youth Team__________ ☐ APSEA :_____________
☐OT _________
☐ PT __________ ☐Medical Doctor_________
Other: (add brief description_)
EDUCATION PLAN
Academic List: Behavior:
☐ PLP ☐ACC ☐MOD☐IND ☐PLP-IBSP ☐ In Progress
☐PLP in process of being created ☐BSAP
☐Other:(add brief description)
Please email this form to:
 District ESS member with whom you are requesting a consult: __________________
 Clinical Coordinator if this is a Child & Youth Team request: _____________________
***For District ESS member or Child &Youth Team involvement requests CC the ESS Coordinator:
 Fredericton Education Center – Judith.lane@nbed.nb.ca
 Oromocto Education Center – cindy.albright@nbed.nb.ca
 Woodstock Education Center – rosemary.brennan@nbed.nb.ca
NOTE: SIW Paraprofessional Requests are to be sent to the ESS Coordinator of your Education Center

September 27, 2017