Student Success Referral

* indicates a required field

Reporter Information

This form is used only for referring students for academic assistance from the Center for Academic Performance. If you believe the student needs additional assistance you can reach out to the Office of Care and Civility at www.unthsc.edu/occ.

Reporter's Name

Reporter's Email Address

Student Support Referral Information

Student's Name

Student ID #

What is the nature of your concern?

Academic Concern Type(s)

Tell us about your academic concerns. Select all that apply.

Please provide additional information or context regarding the support needed.

Please prove you are not a robot