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Student of Concern Referral


This form provides the Le Moyne College faculty, instructors, and employees with a tool for reaching out to and supporting students in need. It allows you to identify students who are in need of additional support beyond what you can provide in your role on campus. This referral form is private and will be reviewed by the E.A.S.E. (Early Alert System Exchange) team. This team strives to provide early intervention and outreach to students who need additional support. If you are concerned about a student, please complete the form below.

*For Emergencies, please call Security at (315)445-4444. In addition, for faculty and instructors, this form does not replace the roster check or the mid-term deficiency grading that you submit to the Registrar's office.

Typical scenarios include:

  • Academic challenges (excessive absences, unusually poor performance, significantly low grades)
  • Struggling with transition to college
  • Uncharacteristic or Inappropriate behavior
  • Unmet emotional or medical needs
  • Major life events causing stress (financial difficulty, food/housing insecurity)
  • Personal/family issues/lack of support structure
  • Possible leave/withdrawal from the college

Your Information

The following fields that have a * before it are fields that are required to be filled out.

 
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Student of Concern

Please provide as many details about the student as possible by answering the following questions:

Involved party 1

Nature of Referral

Please help clarify the area(s) of concern so that we can assist the student.

Enter the nature of your concern:(Required)
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In order for the the College to provide the most effective intervention with this student, it is helpful to know what outreach you have already attempted. Please describe any outreach/discussion, if any, you have had with this student concerning the situation (check all that apply):(Required)
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Submission