Faculty Referral Form

This form is for faculty to flag a student or group of students who may require additional academic support. For concerns about well-being, mental health or behavioural issues, please submit a Care Team referral.

Typical response time: 2 to 3 business days.

PLEASE NOTE: Form submissions will be visible to the employees supporting student success.

Any personal information of a sensitive nature should not be included on the form to protect student privacy.

Faculty are you completing this form for an individual student or group of students? (required)

Individual Student

Group of Students

Faculty Member Name (required)

First Name

Last Name

Faculty Email Address (required)Please enter your Conestoga College staff email account in full. ie bsmith@conestogac.on.ca

Student Name (required)

First Name

Last Name

Please enter the list of student numbers or student emails below. (required)

Student Number (required)

Student's Campus (required)

Student's School

Student's Program Name (required)Type "N/A if unknown program"

Course Name & Course Code (enter n/a if not applicable) (required)

Have you spoken to the student about this concern? (required)

Yes

Please provide details about this concern and/or any relevant conversations you have had with the student(s). (required)

Please be advised when you update this form, you will trigger a message to the faculty/staff that you have reviewed the form and next steps have been taken.

Beware: If you come back into this form and this checkbox is selected, you will trigger another email when your press update.