Application for an Educational Coach

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out this application if you are interested in receiving autism specific support for your registered classes at Utah Valley University.

*Educational Coaching does not guarantee specific grades in courses, but is designed to provide personalized assistance in the classes you choose.

Email *

Personal Information

Full Name

Date of Birth

YYYY

Age

Phone Number

What semester are you requesting an educational coach for?

Fall

Spring

Summer

What would you like help with? (check all that apply)

Time Management

Study Skills

Navigating College

Classroom Skills

Assignment Planning

Communications with Faculty and College Staff

Tutoring

Other:

What are your academic goals this semester?

What motivates you to work on tasks you find difficult?

What are three of your favorite hobbies or areas of special interest?

What do you like to do in your spare time, when there are no expectations or responsibilities placed on you?

Please check the diagnoses you have.

Autism

ADHD

Sensory Processing Disorder

Please list any current or previous health problems you have experienced in the last 4 years (check all that apply)

seizures

head injuries

sleep disturbances

gastrointestinal difficulties

asthma

anxiety

depression

suicidal thoughts

fatigue

Other:

Please list any hospitalizations you have experienced in the last 5 years

Please list any current or previous allergies

Are you currently taking medication?

Yes

Clear selection

If yes, please list all prescribed medication

Have you ever been found responsible for a disciplinary violation at an educational institution you have attended from 9th grade (or the international equivalent) forward, whether related to academic misconduct or behavioral misconduct, that resulted in your probation, suspension, removal, dismissal, or expulsion from the institution?

Yes

Clear selection

If yes, please explain

Have you ever been arrested?

Yes

Clear selection

If yes, please explain

Please check any professional services you receive on a regular basis

Mental Health Therapy

Psychiatric

Other:

When you have a problem, how do you solve it?

Who should we contact in case of emergency? (provide name, phone number, email and relationship to you)

Tell us about your learning style

The next several questions will help us understand how you learn. Please rate your answer based on how closely you agree or disagree with the following statements.

It is easier for me to remember what I have learned when activities are hands on.

Strongly Agree

Strongly Disagree

Clear selection

Written assignments are easy for me to do.

Strongly Agree

Strongly Disagree

Clear selection

I learn better when a book is read to me than when I read silently to myself.

Strongly Agree

Strongly Disagree

Clear selection

I learn best when I study alone.

Strongly Agree

Strongly Disagree

Clear selection

It's harder for me to complete a written assignment than an oral assignment.

Strongly Agree

Strongly Disagree

Clear selection

When I do math problems in my head, I say the numbers to myself.

Strongly Agree

Strongly Disagree

Clear selection

If I need help in class, I will ask a classmate for help.

Strongly Agree

Strongly Disagree

Clear selection

It's easier for me to understand math problems that are written down rather than ones that are read out loud.

Strongly Agree

Strongly Disagree

Clear selection

I do not mind doing written assignments.

Strongly Agree

Strongly Disagree

Clear selection

I remember things I hear better than things I read.

Strongly Agree

Strongly Disagree

Clear selection

I remember more of what I learn when I learn alone.

Strongly Agree

Strongly Disagree

Clear selection

I would rather read a story than listen to it read out loud.

Strongly Agree

Strongly Disagree

Clear selection

I feel that I can express myself better through conversation than in writing.

Strongly Agree

Strongly Disagree

Clear selection

If someone gives me three numbers to add, I can usually get the right answer without having to write them down.

Strongly Agree

Strongly Disagree

Clear selection

I like working in groups because I can learn from those within the group.

Strongly Agree

Strongly Disagree

Clear selection

Written math problems are easier for me to do than oral ones.

Strongly Agree

Strongly Disagree

Clear selection

Writing a word several times helps me remember it.

Strongly Agree

Strongly Disagree

Clear selection

I find it easier to remember what I have heard rather than what I have read.

Strongly Agree

Strongly Disagree

Clear selection

It is more fun to learn with classmates, but it is hard to study with them.

Strongly Agree

Strongly Disagree

Clear selection

I like written directions better than spoken directions.

Strongly Agree

Strongly Disagree

Clear selection

If homework was to be completed orally, I would do all of it.

Strongly Agree

Strongly Disagree

Clear selection

When I hear a phone number read out loud, I can remember it without writing it down.

Strongly Agree

Strongly Disagree

Clear selection

I get more done when I work with someone.

Strongly Agree

Strongly Disagree

Clear selection

Seeing a number is easier for me to comprehend than hearing a number read out loud.

Strongly Agree

Strongly Disagree

Clear selection

I like doing things with my hands, such as simple repairs or crafts.

Strongly Agree

Strongly Disagree

Clear selection

I express myself better through writing, rather than talking with someone.

Strongly Agree

Strongly Disagree

Clear selection

I study best when no one is around to talk or listen to.

Strongly Agree

Strongly Disagree

Clear selection

I would rather read about a subject than have a teacher tell me about it.

Strongly Agree

Strongly Disagree

Clear selection

Speaking is a better way than writing if I want someone to understand me better.

Strongly Agree

Strongly Disagree

Clear selection

When I have a written math problem to do, I read it out loud to myself to help me understand it.

Strongly Agree

Strongly Disagree

Clear selection

I learn more about a subject when I work with a small group of students.

Strongly Agree

Strongly Disagree

Clear selection

Seeing the price of something written down is easier for me to comprehend than having someone else tell me the price.

Strongly Agree

Strongly Disagree

Clear selection

I like to make things with my hands.

Strongly Agree

Strongly Disagree

Clear selection

I like tests that ask for sentence completion or written answers.

Strongly Agree

Strongly Disagree

Clear selection

I understand more about a subject through class discussion rather than from reading about it.

Strongly Agree

Strongly Disagree

Clear selection

I remember the spelling of a word better when I see it written down, rather than if someone spells it out loud.

Strongly Agree

Strongly Disagree

Clear selection

Spelling and grammar rules make it hard for me to clearly say what I want when I write.

Strongly Agree

Strongly Disagree

Clear selection

It's easier to do math problems when I say the numbers to myself.

Strongly Agree

Strongly Disagree

Clear selection

I like studying with other people.

Strongly Agree

Strongly Disagree

Clear selection

I understand what I have learned better when I am involved in making something for the subject.

Strongly Agree

Strongly Disagree

Clear selection

Sometimes I say dumb things, but writing gives me time to correct myself.

Strongly Agree

Strongly Disagree

Clear selection

I do well on test questions that have been talked about in class.

Strongly Agree

Strongly Disagree

Clear selection

I can't think as clearly when I am working with someone else.

Strongly Agree

Strongly Disagree

Clear selection

Educational Assistance

We would like to learn more about your experience with education during your life. Please answer the following questions.

What challenges, if any, do you have in the classroom? (check all that apply)

Not enough time

difficulty writing

sequencing/prioritizing

group instruction

blurting out answers

difficulty with written material

turning in my assignments

asking for help

talking to my teacher

What accommodations have you had in the classroom in the past? (check all that apply)

additional time

assistive technology

calculator

computer

assistance with note taking

preferred seating

distraction free test environment

classroom aide

Other:

Have you ever had an Individualized Education Plan (IEP) while attending school?

Yes

Clear selection

Have you ever had a Behavior Intervention Plan (BIP) while attending school?

Yes

Clear selection

Have you attended classes at UVU before?

Yes

Clear selection

What other universities have you attended, and how many credits?

Why are you seeking a college degree?

What are you getting your degree in?

What are your plans after college?

What career are you planning on?

What are three goals you have for yourself in the next five years?

What would you like to be able to do independently in the next year?

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Utah Valley University. Report Abuse

Forms