Student Referral Form

Please read the following information and then complete, to the best of your ability, the form below. All submissions are funneled through the Office of Student Success and initial contact attempt with referred student occurs within 24 hours of original submission (Monday-Friday only). Based on the information provided, and in accordance to federal and state laws, each submission is referred to the appropriate support service office. *NOTE: Should you experience an emergency situation during a holiday or weekend, please contact Campus Security at 828.328.7146 for more prompt assistance.

*Note to those making submissions: while every effort is made to keep you informed once an “alert” has been submitted, sometimes what may begin as an academic performance issue from your perspective develops into a personal counseling issue. Under these circumstances please understand that we may not be able to notify you of any follow up activity in order to protect the students privacy, not to mention follow federal guidelines. If your cause for concern continues and you have received no response from your original “alert” submission, please contact Mr. Brian Hamm, Director of Student Success & Retention, who will research your original submission to ensure appropriate contact attempts have been made.


This referral is kept in the strictest confidence within the confines of the information provided. Information obtained from this form concerning matters outside the realm of academic performance/success is protected by professional ethical codes regarding confidentiality and will not be disclosed to anyone outside the professional staff within the Office of Student Success & Retention and the Career & Personal Development center without knowledge and written consent of the student being referred. Records maintained in regards to personal counseling are kept separately from student academic records to ensure confidentiality.

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Student Life


Counseling Services
Cornerstone House
Hours: 8 a.m - 5 p.m. M-F
PO Box 7347
Hickory, NC 28603


phone: 828-328-7252
fax: 828-328-7274

Everything you need to apply for admission is right here.