Intervention Alert Form

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.


What is the nature of your concern for the student?


May we share your name with the student?
Yes No

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.)

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
Considering withdrawing