TRIO SSS South Campus INITIAL ASSESSMENT FORM
Basic Information
1. Student Name:
*
First Name
Last Name
2. Email:
*
example@example.com
3. Student ID #:
*
4. Preferred Name:
5. Preferred Pronouns:
6. Date:
*
-
Month
-
Day
Year
mm-dd-yyyy
7. Time:
*
8. Semester:
*
9. Major:
*
10. Success Coach Name: Preferred:
11. Gender Expression:
12. DOB:
*
-
Month
-
Day
Year
mm-dd-yyyy
13. Race:
*
14. Language(s) spoken at home:
*
15. Preferred method of contact:
*
Education & Interests
16. How would you describe yourself academically?
*
17. Are you struggling with any subject? Would you like tutoring?
*
18. Are you involved in any campus or community organizations?
*
19. What motivates you? For example,
*
Accomplishments
Money
Recognition
Family
Security
Faith
Friendships
Power
School
Other
Social
20. Do have a disability that we should know of?
*
21. Are there any triggers that affects your learning (sounds, lights, large crowds)?
*
22. Who is your support system?
*
23. Do you learn better in a group or one-on-one setting?
*
Goals (Short Term, Long Term, Strengths, Weaknesses)
24. What are your academic and life goals?
*
25. Do you have obligations outside of school that will affect your academics?
*
26. What do you identify to be your biggest educational challenges?
*
27. How do you think you can overcome these challenges?
*
28. What would you say your strengths are?
*
29. Do you have access to a computer and internet at home?
*
Yes
No
30. RISK FACTORS IDENTIFIED
*
Academic failure
Lack of commitment to school
Poor social skills
Economic disadvantage
Substance abuse (family/self)
Lack of family involvement
Lack of community involvement
Transportation & Mobility
31. POSITIVE SUPPORT FACTORS IDENTIFIED
*
Grades/school performance
Supportive staff/teachers
Healthy behaviors
Involved in prosocial activities/community
Positive relationships
Stable residence
Economic stability
Food accessibility
32. Risk Level (Please check one)
*
Low (1-2 Risk Factors Identified)
Medium (3-5 Risk Factors Identified)
High (6+ Risk Factors Identified)
33. Questions:
INTEGRATED SUMMARY
34. Enter summary
*
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