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Referred by
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First Name
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Last Name
*
Referrer’s Contact Email
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Name of Student Being Referred
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First Name
*
Last Name
*
Referred Student's SPU ID
(If known)
Nature of Concern
Check any of the following that may be contributing to the student’s situation
Excessive (3 or more) and uncommunicated absences from class
Unsatisfactory progress/failing exams or assignments
Prolonged personal illness
Eating/body image concerns
Seemingly depressed/withdrawn
Stress or excessive worry
Alcohol/drug misuse or abuse
Unresponsive to outreach
Death in the family or significant family crisis
Disruptive/Concerning Classroom Behavior (Behavior a reasonable person would view as substantially or repeatedly interfering with normal class activities. Examples include repeatedly leaving and entering the classroom without authorization, making loud or distracting noises, persisting in speaking without being recognized, or resorting to physical threats or personal insults.)
Withdrawing from SPU
Transferring to another institution
Other:
Other Value
Provide as much detail about the reasons or behavior as possible.
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