Early Intervention at LSC-CyFair

Early Intervention Referral Form

Items in bold are required.

Current Term

Fall 2009

Course Prefix (MATH, ENGL, etc.)
Instructor's Name:	Required

Date: (mm/dd/yyyy)

Required

Student's First Name:

Required

Student's Last Name:

Required

Student's LSCS ID:

Required

Student's Best E-mail:

Best Phone Number (Cell if Possible):

Additional contact number for student:

Course #

Required

Course Section:

Required

If you have taken any pre-emptive action(s) concerning this referral,
please indicate by checking all that apply, and if applicable,
add a comment concerning details or outcome so far:

Comments:

Student needs assistance regarding: (Check all that apply)

Attendance:

Never attended class

Excessive absences

At least one absence during the first 2 weeks of class

Student doing well and abruptly stops attending

Tardiness

Other:

Classroom Behavior:

Sleeping

Not taking notes

Non-participation

Inappropriate behavior

Other:

Personal Counseling:
Other:

Note: Confidential counseling provided by master's level & licensed professional counselors.

Course Completion:

Successful student has unexpectedly withdrawn

Student withdrawn. Please determine reason for withdrawal

Instructor has initiated or is about to withdraw this student for reason noted below