Manual Referral Form

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Areas of Study

Business & Management
Health Sciences
Human Services

Technologies
Trades & Industry
University Studies
Upgrading & Access

Submitter Information

Administrator

Faculty

Operational Staff

Students' Union Representative

Campus Housing Advisor

Course Code & Section Number

if applicable

First time teaching this student

Yes

N/A

First time referring student

Yes

Preferred Phone Number

Select from the following areas you have observed the student struggling with.

Select all that apply.

Appears to be struggling with heavy course load

Could benefit from reduced course load

Does not have the equipment or textbooks needed for their class(es)

Appears unprepared

Appears to have underdeveloped study skills

Appears to have underdeveloped writing skills

Has shown decline in quality of work and grades

Has made multiple requests for extensions

Is falling behind

Has missed more than one assignment

Appears to have/reports difficulty working in groups

Academic misconduct corrective measures and/or sanctions have been applied, as per the Academic Conduct Policy

Reports they have been notified they are on Academic Alert or Probation and seem unsure how to handle this

May need information about and/or support around a Grade Appeal

Is regularly absent or late to class

Personal Resilience/Well-being Concerns

Could benefit from better understanding of academic expectations

Appears overwhelmed by the college experience and academic demands

Shows signs of underdeveloped college/career direction and purpose

Reports they may require academic accommodations due to a medical condition but have not connected with Accessibility Services

Appears to (or reports) struggle with time management

Appears to (or reports) struggle with stress management or self-care

Has disclosed incidents of racism and/ or discrimination (e.g. microaggressions)

Has disclosed feeling othered in the campus community

Has disclosed personal problems (e.g., family conflict, relationship issues)

Has suddenly changed appearance

Has suddenly changed attitude

Has disclosed they are experiencing culture shock

Has disclosed having difficulty transitioning to a new environment

Has disclosed or shows evidence of food or housing insecurity

Has disclosed financial challenges

Mental Health & Medical Concerns

Appears anxious or overwhelmed

Cries or appears tearful

Appears to be distressed, disoriented, or disengaged

Reports they are experiencing depression, anxiety, grief and loss, or other emotional difficulties or mental health concerns

Has disclosed problems with substance use

Has disclosed/you have observed they were involved in a traumatic incident and they potentially require de-briefing and/or support

Reports being impacted by intergenerational trauma

Has disclosed hearing voices or seeing things that other people cannot see

Has disclosed having suicidal thoughts

Has disclosed that they have self-harmed

Has disclosed they are experiencing a health issue

You have observed changes in their physical health (e.g., noticing ongoing coughing, nosebleeds, visible injuries, etc.)

Has disclosed they don’t currently have access to a family doctor and need medical support

Reports or appears to be experiencing memory problems, slurred speech, drowsiness, confusion, or lack of coordination

Non-Academic Misconduct/Safety Concerns

Disrupts the ability of others to learn, or the ability of the instructor to teach

Brings unfounded complaints with malicious or frivolous intent

Displays emotional responses that appear disproportionate to the situation

Makes excessive or unreasonable demands for attention or special treatment from faculty/staff.

Engages in conduct that threatens or endangers the health, safety, well-being of any person

Creates a condition that endangers or threatens destruction of College property or property that is not their own

Was observed or reported engaging in sexual misconduct

Engages in acts that appear to be motivated by hatred or discrimination

Uses electronic devices, online communication, or social media to engage in negative or harmful interpersonal interactions

Engages in verbal abuse, intimidation or harassment

Other concerns or more detailed comments

Areas of Study

Academics

Health & Wellness

Student Support

Amenities

What's Happening

Submitter Information

Student Information

Select from the following areas you have observed the student struggling with.

Academic Concerns

Personal Resilience/Well-being Concerns

Mental Health & Medical Concerns

Non-Academic Misconduct/Safety Concerns

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