George Fox University: Intervention Form

George Fox University | Offices and Services | Student Life | Intervention Form

Intervention Form

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Use this form to alert the Office of Student Life of any student who is struggling academically, socially, or personally, or who may be considering withdrawing from George Fox.

Please indicate if you DO NOT want immediate follow-up with the student by appropriate personnel and are merely completing the Intervention Alert as a point of information.

When appropriate, and unless you have indicated otherwise on this form, this information may be shared with the Student Support Network.

Date

Your name
Your phone
Your e-mail
Student	What is the nature of your concern for the student?
May we share your name with the student? Yes No
Is the student considering withdrawing? Yes No Uncertain
If yes, why is the student considering withdrawing?
What discussion have you had with the student regarding areas of concern?
What kind of follow-up would you recommend? (Leave blank if you don't have recommendations.)
If the student is considering leaving George Fox, do you think the student might consider staying if appropriate contacts are made? Yes No Uncertain
Please list the names of anyone you think might be influential with this person. (Leave blank if you don't have suggestions.)
Check any of the following that may be factors in the student's situation:
Poor class attendance	Desired major not offered	Desire to be with friends
Family/Tragedy	Alcohol or drugs	Boyfriend/Girlfriend problems
Low motivation	Tuition costs too high	Engagement/Marriage
Negative Attitude	Lack of financial aid	Unhappy with academic programs
Academic difficulty	Health problems	Unhappy with university policies
Roommate conflict	Desire to be with family	Unhappy with spiritual life
Unhappy with social life	Unable to get preferred classes	Other

This page was last updated 3-31-2008 09:58:06.
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