Potential Student Screening Intake Form

Your Name

First Name

Last Name

SID Email

Todays Date

Date which P.M.S. is occurring

YYYY

Did you mention this call is being recorded?

Yes

Applicant Information Review

Please VERIFY This Information with them before moving to the next section.

Name

First Name

Last Name

SCC

Date of Birth

YYYY

Phone

(###)

###

####

Home Address

VERIFIED?

YES

QUESTIONS:

What is it that you really want to do and be?

What are you doing really well that is helping you get there?

What are you not doing well that is preventing you from getting there?

Who is the person in your life that you are closest to?

How would this person describe your personality?

What would others say that they do not like about you?

How do you spend most of your time?

Where would you like to be in the next year?

What area of your life do you need the most help? Explain.

How have you handled failure or setbacks in your life?

How would your close family or friends describe your personality?

Yes/No

Is there anything in your past that has helped shaped you?

What is your preferred communication style?

Anything else you'd like to mention?

Or use this section as notes

How long did this session take?