EWS Referral Form

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First Name of Student
Last Name of Student:
Referring Party's First Name:
Referring Party's Last Name:
How do you know the student?:
Is it okay to identify you as the referrer? We will protect confidentiality when possible, if you select no. Yes No
Have you approached the student regarding this issue? Yes No
If no, why not?
If you are a faculty member, in what course is this student enrolled?:
Would you like someone from Academic Advising & Assistance to call you for further discussion, before we contact the student? Yes No
If yes, how would you like us to contact you? Please list a phone number or email address:
Please check off any behaviors or areas of academic difficulty you have observed in the student above:
Not attending class
Excessive absences
Doing poorly on assignments
Not completing assignments
Lacks essential reading/writing skills
Lacks essential mathematics skills
Lack of engagement
Frequent illness
Poor personal hygiene
Perceived emotional issues (e.g. lethargic, depressed)
Disclosure of financial problems
Delay or failure to register for classes
Roommate/Housing issues
Low test or quiz scores
Poor midterm grades
Exhibits poor attitude and/or disruptive behavior in class
Sleeping in class
Excessive excuses for uncompleted tasks
Suspected substance abuse
Traumatic experience
Death of family member or friend
Anger management difficulties
Disrespectful behavior toward faculty/staff
Physically/verbally threatening
Sudden change in appearance
Legal issues
Student discusses leaving Gonzaga
Please provide any additional comments that may help us as we determine a course of action: