EWS Referral Form

Do Not Edit:
Do Not Edit:
Do Not Edit:
Don't Edit This Field:
First Name of Student
Last Name of Student:
Your First Name:
Your Last Name:
Relationship to Student:
Is it okay to identify you as the referrer in conversations with this student? Yes No
Have you approached the student regarding this issue?
If no, please explain
Course Number/Title
Percentage of course work completed at this time:
Would you like someone from Academic Services to call you for further discussion? Yes No
If yes: List cell phone number or email address:
The student appears to be experiencing difficulties in the following areas:
Not attending class/work
Excessive Absences
Doing poorly on assignments
Not completing assignments
Lacks essential reading skills
Lacks essential writing skills
Lacks essential mathematics skills
Lack of engagement in classroom or other activities
Frequent illness
Socially awkward
Poor personal hygiene
Percieved emotional issues (e.g. lethargic, depressed)
Disclosure of financial problems
Delay or failure to register for classes
Failure to obtain ARN in a timely manner
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
Parent/guardian contact
Student discusses leaving Gonzaga