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Referral Form

I: Information on Student being referred

Student's First Name  
     
Student's Last Name    

Student E-mail (if known)

Student Phone # (if known)  

II: Your information

Your relationship to the student (Choose from one of the below)

Self Friend
Family  Roommate
Staff Resident Assistant
URI 101 mentor  
 
Faculty
Name of course Section #
 
Other

Your Name Your E-mail address Your Phone Number (Optional)

III: Referral Information 

Please check off the concerns that you have regarding this student.  You may also write them in the comment section below.

Academics:

Attendance Test Performance
Attitude Class Participation
Assignment Performance Quality of Work
Behavior Lack of Purpose/Motivation

Social:

Social Interaction Problems
Drug Use
Alcohol Use
Personal/Family Difficulties
Little/No Involvement on Campus
Homesickness
Roommate Conflicts/Concerns 
General Unhappiness
Unbalanced Social/Academic Life

Comments:

Does the student know you are referring them?   
Yes     No

Have you discussed the situation with the student?   
Yes     No

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CONTACT INFORMATION

Alix Moffatt
401.874.5527
earlyalerturi@etal.uri.edu
Roosevelt Hall, Room 237

Lydia Hanhardt
401.874.5168
earlyalerturi@etal.uri.edu
Roosevelt Hall, Room 235

In the event of an Emergency
Please contact the On-Campus police
department at
401.874.2121

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