UCBA Success Coaching Interest Form
Name
*
First Name
Last Name
UC Email
*
example@uc.edu
M#
*
M12345678
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you live in on-campus housing?
*
Yes
No
Are you interested in participating in the Success Coaching Program at UCBA?
*
Yes
No
Maybe
I am willing to enroll in MLTI 0095: Success Coaching Seminar, a zero credit hour, biweekly (every other week) course?
*
Yes
No
Maybe
I am willing to meet with my Success Coach once per month to set and review goals and discuss strategies for college success?
*
Yes
No
Maybe
High School Attended
Graduation Year
Are you a first-generation college student?
*
Yes
No
I don't know
Are you a veteran, dependent of a veteran and/or receiving any VA services
Yes
No
Cumulative Grade Point Average (GPA)
Number of credits enrolled in
Do you currently work in addition to going to school?
*
Yes
No
If yes, how many hours a week do you work on average?
Have you completed the FAFSA? If not and you need assistance, please contact Enrollment Services (Muntz 150, (513) 556-1000, or enrollmentservices@uc.edu)
*
Yes
No
Other
How are you feeling about the semester?
*
Not good
1
2
3
4
Very Good
5
1 is Not good, 5 is Very Good
Please explain your answer to the above rating.
*
What barrier(s) (if any) are you facing at this time? (mark all that apply):
*
Academic Preparedness
Course expectations and workload
Poor study habits
Navigating college systems
Work/life/school balance
Deciding a major/career
Technology requirements
Transportation issues
Financial related concerns
Food insecurity
Housing instability
Mental health concerns
Health concerns
Family or household responsibilities
Lack of social support and resources
None at this time
Other
Please describe the barrier(s) marked above in greater detail, and how they have or might impact your success at UCBA.
*
Please mark any campus resources you have utilized to address these barrier(s).
*
Academic Advising
Enrollment Services
Counseling and Psychological Services (CAPS)
Program Coordinator for Social Services Support
Accessibility Resources
TRIO Student Support Services
Student Life & Success
Learning Lab (Math, Writing & Study Skills, Language, Science)
Faculty office hours
None
Other
Describe 2 (or more) strengths which you feel will help you succeed as a student:
*
How can a Success Coach best support you this semester?
*
Do you have any additional questions, comments, or concerns?
We will be in touch to discuss eligibility and next steps.
THANKS FOR COMPLETING THE SURVEY.
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