Student Well-being Team Referral Form

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Personal information and personal health information will be collected by the Student Well-being Team for the purpose of providing students with appropriate services. Personal information is collected under the authority of the Freedom of Information and Protection of Privacy Act section 31(c). Personal health information is collected under the authority of the Health Information Act section 17(1). If you have any questions, see a Student Well-being Team member or contact the Student Well-being Team Program Lead at 16 Fitzroy Street, Charlottetown, PE, Canada, C1A 7N8 or call 902-368-5868.

Identification
Provide information about the student in the fields below.
For example C1B 0X1 or 12345
For example 902-555-5555
Please enter the 8-digits from the student's PEI health card.
For example: Bloomfield Elementary School, Colonel Gray Senior High School, École François-Buote, Immanuel Christian School, home-schooled, etc.
Specify any allergies that the student well-being team should be aware of.
Applicant Information
For example 902-555-5555