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Student Assistance: Faculty/Staff Referral Form
Please use this form to refer students to HSI/SSS. Thank you for taking the time to refer your students.
* Indicates required question
Email
*
Record my email address with my response
Date of referral:
(Month/Day/Year)
*
Your answer
Professor/Staff Requesting Assistance:
(Full Name)
*
Your answer
Student Name:
(Full Name)
*
Your answer
Campus Location:
Ranger
Stephenville
Brownwood
Online
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Subject Area:
*
Your answer
Primary Reason(s) for Referral (Check all that apply):
*
Study Skills (Time management, note taking, test preparation, learning strategies, study habits, etc.)
Academic stress / Goal(s) setting
Attendance
Other Support (Referral to on-campus or community resources)
Career Counseling
Other academic related concerns
Academic Disengagement (attentiveness, class participation, lack of motivation, etc.)
Required
Additional Comments:
Your answer
A copy of your responses will be emailed to .
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