SST Referral Form

Student Support Team Referral
By completing this form, you will be sharing your concern with Southern staff members who are trained in responding to student’s needs. Thank you for making a difference in the lives of our students.

Disclaimer: Upon completion and submission, this form or information contained therein may constitute an educational record of any student(s) referenced and is protected from disclosure except in some limited circumstances. As an educational record of a student, that student may have a right to review the form. The university will endeavor to maintain the information contained in the form as private, to the extent required and allowed by law. Questions regarding the form and its completion or use should be addressed to the Retention Services office. The information contained in this form may be disclosed to appropriate university staff who have an educational need to know for evaluation and/or response. This form must NOT be used to report emergencies.

 
Academic Performance concerns that you have about this student. Check all that apply
Have you addressed these concerns with the student?
Is the student aware of this referral?