STUDENT SERVICES NEEDS ASSESSMENT

Counseling Center

Welcome to Southwestern College!

We are very pleased that you have chosen SWC to provide you with the educational preparation you seek.
We wish to provide you with the exact services you need that will help you to become the most successful
student you can be.

After you complete this form, we will respond to you by e-mail

within 7 business days (Mondays-Friday).
The response you receive will detail for you the next steps you should take to plan your education well.

*Disclaimer: If you provide us with unclear or illegible information, a response may be delayed .

Directions: Please take your time to carefully complete this intake form. Neatly print your name, e-mail and other personal
contact information.
S SWC ID#: 0 - TODAYS DATE:
P L E A S E P R I N T

Name (Last, First, M.I.): Former Name:

E-mail Address:

Cell Phone Number: ( ) - Telephone Number: ( ) -

EDUCATIONAL GOALS

1. Why have you come to the Counseling Center today?

Veteran Request for SEP Graduation Check Probation/Disqualification

Financial Aid Request for SEP Change Major Semester By Semester Plan

Transcript Evaluation Request On Track to Transfer Student Education Plan

2. List at least 3 specific questions that need answers on the day of the counselor appointment.
A. __________________________________________________________________________
B. __________________________________________________________________________
C. __________________________________________________________________________
3. Would you like to request a consultation for personal matters from a therapist at Southwestern College?  Yes  No
4. What college major do you want to study?  Undecided Major

5. Which of the following do you want to complete? (PLEASE CHECK ALL THAT APPLY)

A degree at Southwestern College (AA/AS)?  Yes  No

A certificate (short-term job training) at Southwestern College?  Yes  No
Transfer to a University?  Yes  No
If you plan to transfer, list the University(s) you would like to attend.

________________________________________________________________________________________________
Names of colleges or Universities

6. If you can have any job in the world, what would you choose?

Revised by ZB Counseling Ctr.NAIF 08-15-11 1

Show/No Show
 STUDENT EDUCATIONAL STATUS

7. Please list ALL colleges/universities, including Southwestern College, that you have attended and the number of estimated units
you have completed. (YOU MAY ESTIMATE THE UNITS)

Southwestern College __________ ____________________________________ __________

Name of other college or university units completed Name of other college or university units completed

____________________________________ __________ ____________________________________ __________

Name of other college or university units completed Name of other college or university units completed

____________________________________ __________ ____________________________________ __________

Name of other college or university units completed Name of other college or university units completed

8. Have you requested to have all previous college or university official transcripts sent to Southwestern  Not Applicable
College Admissions Center? Yes  No
9. Are you currently enrolled in one or more classes?
If so, for which semester: (PLEASE CHECK ONLY ONE)  FALL  SPRING  SUMMER  Yes  No
10. If you are a returning or a continuing college student, how many units have you completed (circle one):

1-15 units 16-24 units 25-40 units more than 40 units

11. Have you ever completed a college degree?  Yes  No

If yes, which degree and at which college or university?

_________________________________________________________________ _______________________
Name of other college or University Degree

12. Are you a former foster youth?  Yes  No

13. Do you have high school diploma? GED?  Yes  No

14. If you completed any Advanced Placement (AP) or International Baccalaureate (IB) college credit courses  Not Applicable
while in high school, what scores did you receive? AP  3  4  5
IB  5  6  7
15. Did you attend high school or college in another country?  Yes  No
If yes, what country?

SPECIAL SERVICES YOU ARE RECEIVING

16. Are you currently receiving any of the following? Check all that apply.
Veteran’s benefits?  Yes  No
If yes, which Chapter? (check one)  35  30  31  33
Are you Active Military?  Yes  No

Disability Support Services?  Yes  No

EOPS (Extended Opportunity Program and Services)?  Yes  No

FAFSA Financial Aid?  Yes  No

Cal Works?  Yes  No

ASSESSMENT TESTS

17. Within the last 3 years, have you completed an Assessment exam at another college?  Yes  No
If yes, which college?

__________________________________________________________________________________________________
Name of other college or University

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 Student Name: __ ________________________

SWC #:___________________
“Thank you. We will be in contact within 5 business days to
advise you of your next steps”.
-THE SECTION BELOW IS FOR OFFICE USE ONLY-
Front Staff PRIORITIZE NEXT STEPS
SWC GPA Total (1,2,3…)
Total Units Completed ___CTECS/Steps to an A.A. Degree
Total Degree Units ___Career Assessment Workshop
Yes No Micro-Fiche (prior to 1983)
___Career Research Workshop
Yes No SWC Assessments completed:
___Steps to Transfer Workshop
English
Math Other Recommendations
Reading  Take Assessment Test
ESL  Academic Success Seminar (probation)
Transcripts (On File) Evaluated  Request AP scores & Petition for Credit
1. Yes No Yes No
 Evaluation request form completed and
2. Yes No Yes No
sent, wait for an e-mail from evaluations
3. Yes No Yes No

4. Yes No Yes No

Yes No Probation Seminar

Yes No Has attended a Transfer and/or
Career and/or CTEC Workshop? B.S.I Appointment Yes No
Yes No SEP (Student Educational Plan) E-Mail Sent to Student Yes No
Yes No SxS (Semester By Semester Plan)
Yes No AP Test Scores
Schedule appointment RIGHT AWAY
Yes No Military credit summary only
Yes No Question #3:Therapy appointment
Not Applicable made or referred to schedule?
Counselor Name:
ADDITIONAL STAFF COMMENTS: Date:

Counselor: Turn page over to complete

Staff Name: the Student Learning Outcome.

Date:

Revised by ZB Counseling Ctr.NAIF 08-15-11 3

 STOP!

THE SECTION BELOW WILL BE COMPLETED AFTER YOUR COUNSELING APPOINTMENT.

At the completion of your counseling appointment, please read

the following introduction, and ask your students to rate their
level of understanding on a 5-point scale as follows:

1 = I am unclear on what to do next

3 = I am somewhat clear on what to do next
5 = I am totally clear on what to do next

In our efforts to provide the best service possible to our students,

we are assessing the Student Learning Outcomes for our counseling
appointments. Please rate your level of understanding on a 5-point
scale on the following two questions:

1. I can identify the next steps to follow as a result of completing my

counseling appointment today.

1–3-5

2. I can use the information, materials and resources provided in my SEP or

Semester by Semester to select and enroll in the courses needed to reach
my goal.

1 – 3 - 5 – N/A