Referral Date: __________________________
Your assistance is needed to help facilitate the success, retention, academic progress and timely graduation of Albany
Technical College's students. Please provide the following information about the student(s) in your classes who may be failing
at this time or experiencing other issues that may be affecting his/her academic success. Although we would like to intervene
before the midterm, feel free to use this form anytime during the semester, as you deem necessary. Please return this
completed form via email to
This information is confidential and will be used by the STARS Team
to assist the student. To submit this form as an email attachment, click "Submit at the top right hand corner. This form can
also be “hand-delivered. Thank you for your assistance.
Students Name: ______________________________________ Student ID: ___________________________
Course Title: _________________________________________ Course CRN: _________________________
Program: _________________________________ Email:
Referred By: _________________________________________ Semester: ____________________________
Check appropriate area(s) of concern: __________________________________________________________
Academic Performance Attendance Tutorial Services
Possible Disability Personal Other (explain): ____________________________
Explain the situation and suggest how we can help________________________________________________
This section is to be completed by a STARS Counselor.____________________________________________
Phone Date: _________________ In Person Date: _________________
Email Date: _________________ Letter Date: _________________
Academic Achievement Center Other: ____________________ Date: _______________
Final Disposition ____________________________________________________________________________
Student Completed Course Grade: _____
Student Withdrew From Course
Student Never Made Contact
Revised February 2014