Academic Success Support Form
Please complete the form by filling out the required fields (*) below. Please be sure to indicate each reason for referral by marking all items that apply. This form will be sent to Fahmeen Faruki, Academic Success Counselor, Kathleen Odigé, Academic Success Center Coordinator (Testing and Tutoring Services), and Kim Nicely CARE Counselor.
Diagnostic Medical Sonography
Emergency Medical Services
Health Information Management
Your faculty/staff title
e.g., Nursing Faculty
Your phone number
Student's first and last name
Student's email address
Reason for referral
Please check all that apply.
Communication Skills: Speech/Verbal
Communication Skills: Written
Test Taking Strategies
Needs tutoring services
Grade of “C” or below in two or more courses by mid-semester
Concerning Behaviors (Please explain in special notes or concerns)
Student Needs Support (Please explain in special notes or concerns)
Other (Please explain in special notes or concerns)
Special notes or concerns.
Please provide as much detail as possible.
If you are referring a student due to concerning behaviors or support, has a CARE Report been submitted?
No (If you have not submitted a CARE referral, please use the following link to refer a student of concern:
Send me a copy of my responses.
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