Student Questionnaire
Please fill out and either
e-mail, fax or mail to our office: counseling@excellencematters.com
PO Box 7912, Round Rock, Texas 78683 or Ph. (512)
689-9559, Fax. (512) 670-3294
Name:
Nickname:
Home Address:
Home Telephone:
Home Fax:
E-Mail:
School Name Address (if currently attending):
School Phone:
Social Security Number (optional):
Date of Birth:
For High School and College Students:
Father's Name:
Father's Address:
Father's Home Phone:
Father's Business Phone:
Father's College and Year:
Mother's Name:
Mother's Address:
Mother's Home Phone:
Mother's Business Phone:
Mother's College and Year:
Names, Ages, and School/College attending of Brothers
and Sisters:
List colleges of interest:
1.
2.
3.
4.
5.
College Major:
College Minor:
Standardized Tests Taken (dates and scores):
SSAT _____
SAT I Math _____
SAT I Verbal _____
SAT II Subject Tests ____________________
ACT _____
(1) How would you assess yourself as a student, now
or in the past? Indicate what you consider to be your
strengths and weaknesses. Do you think your transcripts
are a fair evaluation of your academic abilities?
(2) Please list your most important extra-curricular
pursuits, hobbies, and activities, as appropriate.
Specify years of involvement, and positions of leadership
or responsibility.
School Activities:
School Sports:
Outside Activities:
Summer Activities:
Hobbies and Interests:
Honors, Awards, and Recognition (academic and others):
(3) What is your work experience? (please feel free
to attach a resume)
Volunteer Experience?
Internships?
(4) What are your priorities at the moment?
(5) What do you feel you need to be successful, in
an academic, employment, or social environment?
(6) Tell us anything about yourself that would help
us understand you better - your personality, values,
background, interests, aspirations - other significant
people in your life, etc. Please give as thoughtful
a response as possible:
PLEASE NOTE: We would like to have your questionnaire
returned to us prior to our first meeting, along with
academic transcripts, testing information, a resume,
and/or any other materials that you feel would be
helpful to us in the counseling process.
Click here to download form
You can fax the form to (512) 670-3294
or mail form to PO Box 7912, Round Rock, Texas, 78683.
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