We are wanting to check in on you.

Goldenwest College

Leaving your phone & email is optional

Name

First Name

Last Name

Phone

(###)

###

####

Email

Student ID #

Questionnaire

I. Emotionally, what you feeling right now?

II. At this moment in your life, what will you say your NEEDS are?

III. What current challenges are you facing in life?

List how many you'd like

Are you interested in having a One-on-One mentor?