Dillard University Academic Support Services Student Referral Form

Faculty and Staff:
If you have ever found yourself frustrated with the process of referring students who need assistance, you are not alone. A group of Dillard’s academic and administrative colleagues have been working on a common form that will enable anyone to refer a student to the appropriate resources. We plan to pilot the form over the summer, but we need some crucial information from you. Please review the form, ENTER/UPDATE your information and email the form to Shannon Williamson (mwiliamson@dillard.edu) by May 22. Thank you!

Phyllis Worthy Dawkins
Provost and Senior Vice President for Academic Affairs
Dillard University
2601 Gentilly Boulevard
New Orleans, Louisiana 70122
Voice:  504-816-4368
Fax:      504-816-4144
pdawkins@dillard.edu

Past President, Professional and Organizational Development (POD) Network

President Emerita, HBCU Faculty Development Network

Student Information

Date of Referral ___________            ID# ____________     Phone# (Current): ____________________________

Student’s Name _______________________________ Student’s Email _______________________________

Procedure for Referring Students:

1.      The Faculty/Staff member completes the Student Referral Form for each student he/she is referring to the appropriate service.

2.      Scan and email or fax the form to the appropriate location. Give the student a copy as well.

3.      After the session is over, the student provides proof of attendance to the Faculty/Staff member who referred them.

If you have questions about this form, please e-mail Dr. Kevin Bastian at kbastian@dillard.edu

ü	Support Service	Location	Phone	Fax
	Academic Advisors	Varies	varies	varies
	Academic Affairs (Office of)	Rosenwald 203		X4144
	Admissions (Transfer credits)
	Business and Finance	Rosenwald 106A	x.	x. 4644
	Campus Activities and Student Engagement	Student Union 270 Student Union 277	x. 4885 x. 4885	x.4063 x. 4072
	Campus Security/Threat Assessment (safety and security)	Public Safety	x. 4954	x. 5310
	Chaplain	Lawless 102	x.4250	x.4792
	Career and Professional Development	Student Union 239	x. 4885	x. 4656
	Center for the First Year Experience	Dent 206	x. 4918	x. 4863
	Financial Aid and Scholarships	Rosenwald 126	x. 5456	x. 4677
	Foreign Language Support		x.	x.
	Library Services	Library 1st Floor	x. 4786
	Louisiana Alliance for Minority Participation (LAMP)		x.
	Personal Counseling	Dent 113	x. 4956	x. 4186
	Psychiatrist	Student Union 166	x.	x.4169
	Records and Registration	Rosenwald 116	x.	x. 4705
	Residential Life	Williams 114	x.	x. 4734
	Student and Judicial Affairs	Student Union 239	x. 4885	x. 4685
	Student Health and Wellness	Student Union 172	x. 4680	x. 4532
	Student Success (Office of)	Rosenwald 111	x. 4263
	Student Support Services: Tutoring for Math, Science, Building Study Skills (Circle All That Apply)	Dent 110	x. 4956	x. 4306
	Undergraduate Research	DUICEF 247	x.	x. 4527
	Writing Center	Dent 162	x.	x. 4180
	Other (write in other information):

Faculty/Staff: In the space below please provide a brief description of the reason for your referral. Include your observations of the student’s behavior and concerns the student has shared with you. Attach any additional information as you see fit.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I understand the reason I am being referred and will follow up on this referral. Student’s Signature:  ____________________________

	Printed Name	Signature	Date	Department	Phone
Referral Source
Receiving Faculty/Staff

Dillard University Academic Support Services Student Referral Form