Center for Student Success Freshman Intake Form

Center for Student Success

 

Last Name

First Name

M.I.

Student Number

Success Coach/Advisor Barbara Jacobs Kishera Reddick

Semester Fall Spring Summer

Proposed Major COMPUTER INFORMATION SYSTEMS COMPUTER SCIENCE WEB DEVELOPMENT COMPUTER NETWORKING TECHNOLOGY CHILD DEVELOPMENT GENERAL STUDIES LOUISIANA TRANSFER Arts LOUISIANA TRANSFER Science CRIMINAL JUSTICE ADMINISTRATION AIRFRAME/POWERPLANT MAINT. TECH. DENTAL HYGIENE HEALTH INFORMATION TECHNOLOGY MEDICAL CODING SPECIALIST HEALTHCARE ACCESS ASSOCIATE EMERGENCY MED TECHN-BASIC EMERGENCY MED TECHN-PARAMEDIC RESPIRATORY THERAPY SURGICAL TECHNOLOGY RADIOLOGIC TECHNOLOGY POLYSOMNOGRAPHIC TECHNOLOGY MEDICAL LABORATORY TECHNICIAN PHLEBOTOMY DIALYSIS TECHNICIAN STERILE PROCESSING TECHNICIAN HUMAN SERVICES NURSING BUSINESS MANAGEMENT ACCOUNTING ACCOUNTING TECHNOLOGY CLERK ADMINISTRATIVE TECHNOL SPECLST

Address

Home Phone

Cell Phone

What is the best way to contact you? (text, cell phone)

Other?

Email Address

Ethnicity (check appropriate box):

Needs Analysis

Do you need assistance with any of the following (check all that apply):

Educational Data

Why did you decide to go to college?

What brought you to SUSLA?

Did you see/hear any SUSLA advertisement?

If yes, which ones?

Has anyone in your family (parents, brothers and sisters) attended college?

Has anyone in your family (parents, brothers and sisters) graduated from college?

Do you have a personal computer?

Have you ever taken online courses?

Career Plans

What is your Career goal?

When do you expect to have accomplished your goals?

How much money do you plan to earn per year?

Please rate your time management skills in the following areas:

Punctuality (arriving to school, work, or other activities)

Finishing tasks on time (meeting deadlines)

Maintaining schedules

Are there any subjects (i.e. math, reading, science, etc.) you need help with?

If yes which one(s)?

Special Interests

When was your greatest accomplishment?

When did you last perform your best?

What did you do?

How did you prepare?

What are your favorite subjects?

What are you interested in the most?

What do you do best?

Have others told you that you were good at something?

If so, what is it?

What awards, diplomas, certificates, etc. do you have?

Are you a member of any social/religious organization(s)?

Which organization(s)?

Work Data

Do you intend to work while attending college?

On average, how many hours each week will you work?

Are you interested in Work Study (Employment outside the college):

Do you have dependents (children or otherYesNo family members) that you care for?

Motivation Factors, Academic Preparedness

Do you think you are prepared academically for college?

Are certain courses more difficult than others?

Which ones? (Please select the area of most difficulty for you)

Are you confused about your choice of major career plans?

Do you feel that college is the best way to achieve your goals?

Do you like to be challenged when learning something new?

Social Life

Do you enjoy socializing (i.e. dating, outings with friends, etc.) with others?

How many hours per week do you socialize with others?

Test Anxiety, Lack of Concentration

Does taking tests bother you?

Please describe specifically how you feel when taking tests.

Do you have difficulty finishing tests?

Do you get distracted easily when studying?

What appears to distract you the most when studying?

If you selected "other", what distraction(s) (not listed above) affect you?

Study Habits

How many hours per day do you devote to studying?

Are you able to find a quiet, comfortable place to study?

Did you thoroughly read through your assignment(s)?

How often do you engage in the following behaviors?

Take good lecture notes in class

Rewrite or reword your notes after class

Review your notes before each class period

Do you cram for exams?

Do you study alone?

With whom do you study?

Do you think your other commitments will affect your study time?

Based on your study habits, will you seek tutoring?

What other problems may interfere with your studies? (Please check all that apply.)

Other distraction(s), if applicable (please explain):