Referral Form

Complete this form to refer a student to an academic support department.

Note: this form is designed for the UIC Professional and should only be submitted with full understanding and consent by the student.

Student Referral Form

  • Student Contact Information

  • Student Name * Required
  • Enter a valid UIC Email
  • Refer to

    At least one (1) selection is required. Only one (1) department per referral.
  • NOTE: The student will be contact within 24 hours by the selected department * Required
  • Referral Reason

    Select one or more of the areas listed below that you and the student have determined to be areas for further development. Use the Brief Description text fields below to provide insight into the strengths and assets of the student and/or further explanation of the challenges that have been identified.
  • Non-cognitive Academic Factors and Skill Areas * Required
    Select the primary reason(s) for the referral (all that apply).
  • Select the items below based on student disclosure (all that apply).
  • Other Areas and Additional Notes

  • Learning and Attention Areas
    Select the items below based on student disclosure (all that apply).
  • Additional notes for the unit to know. (If none of the above selections are truly applicable to the reason(s) for the referral and you would like to describe the assistance needed. please do so in the field below.
  • UIC Referral Professional

    Notification of this referral will be sent to the selected support department AND a notification will be sent to the student AND the referrer will be cc'd
  • Name * Required
  • Student Consent * Required
  • Click 'Schedule Appointment' to submit this form and book an appointment with UIC Appointment Scheduler.