Iowa Wesleyan College

Student Alert Referral

Name:
Ext.:
Email:
Relationship to Student (Instructor, advisor, coach, work-study supervisor, etc.):
Course:
Name:
ID#:
Please indicate which of the following best describes the student's situation:
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Faculty/Staff Information Student Information Lack of attendance in class; course: Lack of attendance at work; office and position: Student appears to be having academic issues that may require assistance
(e.g. failing to complete assignments; appears to be struggling with readings, etc.) Student is not prepared for class Student requires study skills assistance Student does not work to his/her ability Student is not utilizing the services of the Academic Resource Center or other services as prescribed Student is having difficulty with major and/or career decisions Other academic issue: Student appears to be having personal issues that may require assistance(e.g. Roommate issues, financial concerns; adjustment issues; etc.) Student has a housing/roommate concern Student is not adapting well socially Student appears to have a substance abuse concern Extra-curricular activity appears to be interfering with academic success Student is having difficulty identifying extra-curricular activities that meet his/her interests Personal problems appear to be interfering with social adaptation and academic success Other personal issue: Student appears to be having health/wellness issues that may require assistance(e.g. falls alseep in class; hygiene concerns; apparent chronic illness; etc.) Explain: Student appears to be having other problems that may require assistance(e.g. significant decrease in performance; major change in demeanor; etc.) Explain: In addition to this form, what actions, if any, have you taken to assist the student with the concerns you've identified: Comments: The student is aware that I am making this referral: Yes No Last date attended: Comments: Last date attended: Comments: