Student Referral System
FACULTY/STAFF INFORMATION
Your First Name
Your Last Name
Your Northeast State Email Address
Your Office/Department
STUDENT INFORMATION
Student's First Name
Student's Last Name
Student ID
Do you believe the student is active military or a veteran?
Yes
No
Do you have an accommodation letter from Accessibility Services on file for this student?
Yes
No
If yes, please contact Accessibility Services at 423.279.7640, on-campus extension 7640, or email
accessibility@NortheastState.edu
to initiate an Accessibility Services referral for this student. Do not comment in the box below.
Is the student a dual enrollment student?
Yes
No
Reason(s) for referral (mark all that apply):
Unsatisfactory Attendance
Number of classes missed by student:
Never Attended
1
2
3
4
5
6
7
8
9
10
Is the missed attendance related to lack of childcare?
Yes
No
Online Engagement
Poor Academic Performance
Once referred, please inform the student that academic support services and free tutoring are available in The Learning Center.
Student Needs Project
Socioeconomic Needs (Food, Shelter, Transportation, Career Clothing)
Assistance available through the Student Needs Project does not include direct financial payments of tuition/maintenance fees and/or textbooks/supplies.
Personal Counseling
Personal/Emotional Issues
Please contact Counseling Services at 423.354.5308, on-campus extension 3211, or email
counseling@NortheastState.edu
to initiate a counseling referral. Do not comment in the box below.
When students verbally express or write a direct threat to harm self or a direct threat to harm others immediately call Campus Police at 423.677.7927.
Please enter the course you are referring the student from:
-
(Example: ENGL 1100 - A01)
Subject
Course #
Section
Further information/explanation of referral: Please do not include accessibility or counseling referrals in your comments. See Accessibility Services or Counseling Services contact information above. Please note that your comments become part of the student's education records. FERPA applies to all information submitted.