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Early Alert Referral

Thank you for your concern and willingness to refer a student to the Cougar Success team.   Please fill out and submit this form so that we can assist the student in working through any issues that may impede his or her success.

The information that you provide on this form is vital and will aid us in helping the student as quickly as possible.   This form will be sent to the most appropriate person for intervention.

Please note that the information you provide is not confidential and will be used in our outreach effort to assist the student.

Please fill out the following information and click SUBMIT. All fields are required.

Student's first name: A value is required.
Student's last name: A value is required.
Your first name:
Your last name:
Your e-mail:

I am a: Faculty Member

Staff Member



Please identify the problem or concern


The student is not attending class.

The student performs poorly on quizzes and / or exams.

The student has missed quizzes and / or exams.

The student is not participating in class.

The student is having difficulty completing assignments. (Student is turning in assignments late.)

The student's performance has dropped; the quality of the student's work has diminished.

The quality of the student's written work is poor.

The quality of the student's oral work is poor.

The content of the course appears to be difficult for the student.

The student has not accessed course materials (syllabus, assignments) on the course Moodle site.

Attitudinal / Personal

The student is exhibiting a poor attitude.

The student appears to have problems interacting socially.

The student appears to have personal problems.

The student has exhibited problems adjusting to college life.

The student is showing signs of depression, sadness, loneliness, homesickness.

The student's physically appearance has drastically changed.


Do you recommend tutorial assistance for this student? Please specify in which area(s):




Mathematics / Sciences

Study Skills

Please provide any additional information if possible:

Please describe what has already been done to address the problem and the person involved:

Do you have specific requests on how the Cougar Success Team can help this student?

Please select the most appropriate person to send this form to.   If you are not sure who that person should be, select the General Referral category. Referrals are reviewed by the Cougar Success Team for appropriate follow up and intervention.




Academic Support

Referral goes to Holly Kilby and Mary Vanderlinden

Writing Support

Referral goes to Alana Adkins and Mary Vanderlinden

Testing for Learning Disability

Referral goes to Mary Vanderlinden, Holly Kilby, and Joan Kahwajy-Anderson

Classroom Behavior   / Lack of Attendance

Referral goes to Mary Vanderlinden

Out of Class Behavior

Referral goes to Lesley Villarose and Marsha Foster

Concern for International Student

Referral goes to Lesley Villarose

Health Concerns

Referral goes to Joan Kahwajy-Anderson

Social Adjustment Concerns

Referral goes to Joan Kahwajy-Anderson

Risk of Threat or Violent Behavior

Referral goes to Mary Vanderlinden, Lesley Villarose, and Joan Kahwajy-Anderson

Financial Concerns

Referral goes to Carl Bradsher

Student Athlete

Referral goes to Mary Vanderlinden

Other Concerns Not Listed

Referral goes to Mary Vanderlinden

Please type AVERETT in the box.

Cougar Success Team
Lesley Villarose, Dean of Students
Carl Bradsher, Dean - Financial Assistance
Mary Vanderlinden, Assistant Dean - Student Success
Alana Adkins, Director - Writing Support
Holly Kilby, Director - Academic Support
Joan Kahwajy-Anderson, Counselor
Marsha Foster, Director - Residence Life


Cougar Success Early
Referral Form

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