Accessibility Resources Coaching Intake Survey

Name *

First Name Last Name

UC Email *

example@mail.uc.edu

Student ID (M-Number) *

M########. Can also be found on your student ID.

Date *

Month Day Year

What is your major? What are some career options are you considering?

What are your strengths areas? Subjects you understand well? Personal habits that help you be more successful?

What areas do you struggle with? Subjects that are hard? Personal habits, like maybe being a procrastinator? Or unorganized? Or disability issues that interfere with school or your life in general?

Time Management: Please fill in the boxes below with the number of hours per week that you spend on:

Hours per Week

Attending Class

Doing homework

Free time

Working

Please rate how effectively you manage your class assignments/homework.

	1	2	3	4	5

1 is Behind Schedule, 5 is Caught Up and On Time

Study Habits: My current study habits are?

I use these materials when I study:

Notes Class Materials/PowerPoint Flashcards Practice Questions and Tests Textbook Homework Previous Quizzes and Exams Internet/Videos

Please rate how effective you believe your current study habits are:

	1	2	3	4	5

1 is Very Poor, 5 is Excellent

My note taking habits are?

I use these methods for taking notes:

Write down key topics Summarize material Highlight/marking on materials Taking notes while reading the textbook and other materials Taking notes during class lectures

Please rate how effective your current note taking habits are:

	1	2	3	4	5

1 is Very Poor, 5 is Excellent

My expectations for coaching are?

I would like coaching sessions to be a space to:

Try new study skills Get myself organized Learn about new resources (on campus and materials) Draft an email with coach input (for a professor or advisor) To hold me accountable for my own goals Create a schedule and figure out other ways to manage my time

Please check all that apply:

Have my own computer Have a computer setup with multiple screens Have access to a printer Have a quiet space to study Have all of my textbooks (in either digital or hardcopy format)

Please list your classes below. Include class name and any concerns about each class.

Course Name

Concerns

Class 1

Class 2

Class 3

Class 4

Class 5

Class 6