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AST Referral Form
1. What is the best way to contact you?
2. Academic Performance concerns that you have about this student. (Check all that apply)
Academic difficulty due to gaps in foundational skills
Difficulty adjusting to college life
Experiencing test anxiety
Falling asleep in class
Marked decline in performance
Poor class attendance
Time management and procrastination issues
3. Other (Please provide additional information)
4. Have you addressed these concerns with the student?
Yes
No
5. Is the student aware of this referral?
Yes
No
6.
This student is in the Adult Completion Program (ADC)
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