Lakehead District School Board
  Ontario
Self-Referral
Please tell us how we can help you:
Please tell us who you are
Salutation:
* First Name:
Middle Name:
Last Name:
Preferred Name:
Date of Birth:
Select Date
Age:
Gender:
Please tell us how we can contact you
Preferred Language:
Please include the area code with phone number.
You can provide additional details to the phone number provided in the adjacent comments box.
Home/Main Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Work Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Alternate Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email Address:
Address:
:
City:
Province:
Country:
Postal Code:
Hide/ShowSchool
Please tell us what school you attend:
What grade are you in?
Permission to contact student via Edsby (high school only)
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Presenting Issues
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Name of person completing the referral:
Role of person completing the referral:
 
Are you currently receiving counselling services in the community?
Yes
No
What agency?
Please note if you are currently receiving services from a community counsellor you may not be eligible for school counselling services.
 
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All information is protected under Ontario privacy legislation and is kept confidential.