Student Self-Referral Form Students, fill this form out if you are in need of any assistance–individual academic support, financial or any other type of assistance. Please do not disclose HIPAA or FERPA related information on this form. Self-Referral for Student Assistance Please fill out this form to request assistance. Someone from the Office of Student Success will contact you within 1-2 business days. Please note that information shared will be kept confidential. Do not share health-related information on this form. Name First Last Email PhoneProgram/TrackTraditional BSNAccelerated BSNRN to BSNBSN to DNPPostmaster's DNPCertificate ProgramPhDType of Assistance Requested*TutoringDisability/AccessOther (includes counseling, hardship etc)Provide details as needed (please do not disclose protected health information in this form).How would you prefer to be contacted?PhoneEmailThird Choice
