Langley Secondary School

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Our School
News & Events
Special Programs
Courses
Student Life
Staff Connection
Parent Community
Learning Commons

Special Programs

FOCUS School Based Team Intake

FOCUS Intake

School Based Team Referee Filling Out Form*
First Last
Role within School*
SBT Administrator
First Last
SBT Counsellor
First Last
SBT Resource Teacher
First Last
Current School*
Student Being Referred*
First Last
Aboriginal Ancestry?*
- Yes
- No
Date of Birth (Month - Day - Year)*
Current Grade*
Is the student designated? If so, please list below:
Parent/Guardian's Name*
Parent/Guardian Contact Number*
Parent/Guardian Email*
Parent is aware of FOCUS referral?*
- Yes
- No
Reasons for potential placement in the Focus Program*
Please list the adults who are supporting/connected to this student
Does the student struggle with attendance? Explain.
Will this student need any specific parameters/guidelines in place before entry to the program to ensure the likelihood of success? Explain.
Courses Completed
- English9
- English 10
- English 11
- English 12
- Career Life Education 10
- Career Life Connects 12
- Capstone
- Science 9
- Science 10
- Any Science 11
- Social Studies 9
- Social Studies 10
- Any Social Studies 12
- Mathematics 9
- Workplace Math 10
- Workplace Math 11
- Foundations and Pre-Calculus Math 10
- Foundations Math 11
- Pre-Calculus Math 11
- Physical and Health Education 10
Key Support Information
- IEP/Psych Ed Report
- Safety Plan
- Positive Behaviour Support Plan
- VTRA(s)
- Attended Project Resiliency
- History of self-harm (any suicide ideation, attempts, extreme high risk behaviour, etc...)
- History of harming others (any violence towards others, threats of violence, aggressive conduct, etc...)
- History of weapons.
- History of drug use/abuse.
- Requesting Administrator phone call prior to enrolment
Any Additional Information (e.g designation, pertinent IEP info, triggers, diagnosis etc)

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Langley Secondary School

21405 - 56 Avenue, Langley
BC, V2Y 2N1
Phone: 604-534-4171
Fax: 604-534-9518

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