Today's Date

Referred By

Email

Student Name

Course

Department

Telephone

Academic Concerns

Excessive absences
Habitual tardiness to class
Late or missed assignments
Grade point below "C"
Repeated attempts to gain extensions or postpone tests
Poor examination results
English language literacy concerns
Study skills assistance recommended
Peer tutoring suggested
Withdrawal from course is advised

Personal Concerns

Depressed, apathetic, or low interest/motivation
Disruptive behaviors a concern
Noticeable change in appearance or behavior
Exaggerated or inappropriate emotional responses to situations
Suspected alcohol or drug use
Medical or family concerns
Financial stress

Student has met with you to discuss problems?
Yes
No

Specific needs that should be addressed to enable this student to be successful in your class:

Additional comments that would aid the Learning Center in helping this student: