MavCARES Referral Form

The purpose of the Early Alert Referral is to give faculty, staff, students and/or parents the opportunity to refer a student who has an academic concern such as excessive absences, a failing letter grade, or concerning behavior. The referral will go to the Office of New Student and Family Programs who will assess the situation, offer support and provide referrals to the appropriate resources on campus.

NOTE: In accordance with the Family and Privacy Act (FERPA), the structure is designed to allow referrals to be viewed only by those individuals who have a need to know. The information shared will not become a part of a student's permanent record. In addition, state and federal privacy laws prohibit the unauthorized disclosure of personally identifiable health information.

Referred by (Your name): Please specify

Your e-mail address: Please specify

Your phone number: Please specify

In what context do you know the student? Please specify
Parent Roommate Advisor Instructor Friend Classmate Staff Family member Other

Student's name (first and last): Please specify

Tech ID number (if known):

Student class status:
First-year Sophomore Junior Senior

E-mail address:

Cell Phone number:

On or Off campus residence?
On-campus Off-campus

Comments on the contact information:

Academic Issues:
Grades
Attendance
Homework
Other. Please explain below:

Is this issue related to a specific course?
Yes. Course #:
No.

Have you already discussed the issue with the student? Please specify
Yes No

Is this an issue that is URGENT (needing assistance in the next 24 hours) or IMPORTANT (action needed within 3 working days)? Please specify
Urgent Important

** This service is monitored during regular office hours, not 24/7. **

Explain the situation and suggest how we can help.