Academic Advising Referral Form

This form is designed to initiate academic advising outreach to current undergraduate students. An academic advising referral is appropriate for any current student experiencing academic difficulty or personal circumstances that are impacting their academics. However, this form is designed specifically for students with sensitive or complex needs who would benefit from a personalized outreach and an expedited response from advising.

Once submitted, a Faculty-specific Academic Advisor will contact the student within two business days to offer support, assess needs, discuss options and next steps, and help connect them with the most appropriate campus resources.

The information provided is confidential and will be used solely to initiate advising outreach and to offer advisors the context needed to support the student effectively. Please ensure the student is aware that a referral is being made and that relevant information is being shared to facilitate this support.

If you would like a copy of the completed referral for your records, simply include your email address in the form and a copy will be sent to you.

Student Name Student Name First Last
Preferred Name
Student Number
Must be 9 digits. Currently Entered: 1 digits.
Referred by: Referred by: First Last
Faculty/Department/Service

What area is this student being referred from?
The above mentioned student has provided consent to share this information for the purpose of referral to academic advising for personalized outreach and support.
I would like to be included in the outreach to the student, and the student has agreed to my inclusion.
Information that would provide helpful context for Academic Advising outreach and support:
The best way for academic advising to connect with this student is:

The best way for academic advising to connect with this student is: Ontario Tech .Net Email Phone (input here) Phone (input here)
When Advising connects with the student would it be beneficial to reinforce connection to any other services that you have either already recommended or see need for?

When Advising connects with the student would it be beneficial to reinforce connection to any other services that you have either already recommended or see need for? Financial Aid Accessibility Services Student Learning Centre Mental Health Services Other Other

Advising will discuss these resources with the student.
Do you anticipate that your service/department will continue to be involved in supporting this student beyond this referral?

This will help us understand the support system and resources in place for the student.
Please include your email address if you would like to recieve a copy of the referral.
Personal information on this form is collected under the authority of the University of Ontario Institute of Technology Act, SO 2002, c. 8, Sch. O. and will be collected, protected, used, disclosed and retained in compliance with Ontario’s Freedom of Information and Protection of Privacy Act R.S.O. 1990, c. F.31. This information will be used by Student Accessibility Services for/to *insert purpose here*. Questions regarding the collection of your personal information may be directed to: Ontario Tech University Access and Privacy Office, 2000 Simcoe Street North, Oshawa, ON L1G 0C5, 905.721.8668, ext. 6705, email: accessandprivacy@ontariotechu.ca.