Community Standards and Student Advocacy (CSSA)
~Mandatory Counseling Assessment~
Educational Sanction Assignment Due Date: ____________________
Counseling Center Staff,
The following student (print full name): _________________________________________ has been given
an educational sanction of a mandatory counseling assessment. Please let this document serve as confirmation
that the student is aware of the following:
1. It is the student’s responsibility to contact the counseling center to schedule an appointment within two
weeks of receiving their conduct decision letter.
2. It is the student’s responsibility to ensure that their appointments are scheduled and completed within
the assigned deadlines.
3. It is the student’s responsibility to sign an authorization to release information to the Office of
Community Standards and Student Advocacy for the following information: date of scheduled
assessment and students’ compliance or refusal to complete assessment.
4. It is the student’s responsibility to inform the Office of CSSA prior to any due date(s) if personal
circumstances prevent the student from meeting any sanctioning requirements and/or deadlines.
_______________________________________________
Student Signature
_____________________
Date
Office Use Only
Staff Signature & Date
 The above student successfully completed the
counseling educational sanction.
o Date of completion:_______________
 The above student did NOT successfully
complete the counseling educational sanction.
Community Standards and Student Advocacy
Office Location: A2120C
Phone: 708.235.2845
Email: [email protected]
Website: www.govst.edu/cssa