REFER Form

The offices of Academic Advising & Assistance and the Center for Cura Personalis now oversee the Student Referral Form which combines the previous efforts of the Early Warning System and Student of Concern form into one seamless, comprehensive program, used to identify students who may be at risk, both academically and/or for whom you have emotional, social, or behavioral concerns. Your referrals will initiate our processes to identify and provide support to these students. Please know that our offices make every effort to contact referred students within 1-2 business days and that some action is taken on every form that is received.

Form submissions are not monitored outside of normal business hours, including weekends and University holidays. If you have immediate concerns about the health or safety of a student, or for the Gonzaga community, please call Campus Security and Public Safety at 509-313-2222, or 911. For questions about the program, or to refer via phone, please contact our offices using the information here:

Center for Cura Personalis

729 E Boone
509-313-2227
ccp@gonzaga.edu

Academic Advising and Assistance

Foley 122
509-313-4072
advise@gonzaga.edu

In order to best serve our students, please provide as much information as possible in the form below.

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* = Required Fields
Referring Party Contact Information
Yes No
Who are you referring?
On Campus Off Campus Unknown
Nature of Concern
Academic

Primary Secondary
Check all that apply:
  • Sudden and significant decline in academic performance
  • Excessive absences
  • Failing to turn in assignments
  • Numerous requests for allowances or accommodations in regards to assignments/attendance, etc
  • Misuse of accommodations
  • Unresponsive to outreach
  • Student discusses leaving GU
  • Delay/failure to register
  • Lacks essential reading/writing/or mathematics skills
  • Lack of engagement in classroom/activities
  • Low test/quiz scores
  • Sleeping in class
  • Disruptive behavior in the classroom
  • Other:

Yes No
Well-Being/Behavioral

Primary Secondary
Check all that apply:
  • Disruptive behavior
  • Disturbing behavior
  • Sudden change in mood or demeanor
  • Concerning use of alcohol or drugs
  • Self harm behaviors (cutting, scratching, etc)
  • Potentially risky behaviors (restricted eating, excessive exercising, binging and purging, misuse of medications, etc)
  • Expressions/thoughts of wanting to harm self or others
  • Frequent or persistent illness
  • Transition Issues
  • Loss of friend or family member
  • Relationship issues
  • Sexual assault
  • Domestic violence
  • Physical or sexual abuse
  • Depressed state or anxious beyond what seems normal
  • Thoughts or threats of suicide
  • Other:
Yes No