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Confidential Reference Form

Halifax Independent School

Confidential Reference (Pre-Primary/Primary)

Please complete this online form at your earliest convenience. Should you have any technical difficulty with this form, please call us (902-423-9777) We would gladly arrange a time to collect your reference by phone. Thank you!

Your Info

Your name (first and last) *

Job title/Position *

Name of daycare centre/school *

(if applicable)

Your daytime phone # *

Your email *

Thank you for helping us get to know this child.

Child's Name (first and last) *

How long have you known this child? *

In what capacity have you known this child? *

Describe this child's current strengths. *

Describe strategies that this child currently uses to handle conflict or frustration. *

As of this date, how dependably does this child recognize and appropriately respond to the need to use the toilet? *

Re: Current toileting self-help skills regularly demonstrated by this child *

sitting comfortably on the toilet

effective wiping

effective hand hygiene

effective handling of clothing during uneventful bathroom trips

moving through toiletting tasks with caregiver prompts

completing toiletting tasks unprompted

appropriate use of toilet tissue/paper towel/taps

asking for help if/when needed

We appreciate that toileting is a work in progress. Please give us a snapshot of this child's current mastery of self-help skills around toiletting.

Please give details about any necessary supports/prompts and current challenges around toiletting for this child. *

Re: Current demonstrated self-help dressing skills, please check all that apply. *

gathers needed items (e.g., from their hook/cubby/bag)

moves through dressing steps unprompted

initiates change of clothing/footwear when wet/soiled

usually handles fasteners (e.g., zippers, snaps, buttons independently

Please give details about any necessary supports/prompts and current challenges around clothing/outdoor gear for this child. *

Re: self-help feeding skills/attitudes, please check all that apply. *

demonstrates positive feelings toward eating and drinking

routinely manages and uses an open cup

is typically open to trying unfamiliar foods

successfully uses a spoon/fork

readily participates in tasks around meals/snacks (e.g., setting /clearing the table)

Please give details about any necessary supports/prompts and current challenges around feeding for this child. *

Describe skills and concepts on which this child is actively working. *

Please give details re: any additional specific supports that you consider essential for this child in your childcare setting. *

Describe how this child handles prompted transitions from one activity to another. *

Share your observations about this child's experience with group activities. *

Describe this child's current level of interest in letters. *

At this point, does this child recognize their written (i.e., printed) name? *

No

Occasionally

Usually

Yes (dependably)

Please provide any other information about this child that you consider important. *

Share your experience with this child's parent(s) or guardian(s).

Based on your experience, use the checkboxes below to describe the support of the main parent(s)/guardian(s) for this child. *

caring and supportive

mostly supportive

indifferent

unsupportive

Based on your observations, use the checkboxes below to describe the working relationship between this child's parent(s)/guardian(s) and you (and/or your colleagues). *

respectful and productive

mostly constructive

minimally engaged

problematic and/or unproductive

Have you had any experience discussing a concern or a challenging topic with this child's parent(s)/guardian(s)? *

Yes

No

Please describe their participation and reaction, and their receptivity to discussion. *

Anything else?

Feel free to share anything else that you consider important. *

If you are human, leave this field blank.

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