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New Student Intake Form

Returning?

A A A

Thank you for your interest in meeting with a learning specialist. In order to give you the best experience/outcomes as possible, we would like for you to fill in the following information. If you have any questions or concerns about this form, please call us at 501.526.6003 or email us at abisbee@uams.edu.

Note: This form is for INITIAL appointments with Learning Specialists only. If you have met with a Learning Specialist at UAMS before, please mark "Follow-Up" below and choose to exit the survey when the pop-up appears. Instructions for follow-up appointments will appear on the next screen.

What type of appointment are you interested in?

Student ID (UAMS ID on your badge)

* must provide value

Contact Date

* must provide value

M-D-Y

Student First Name

* must provide value

Student Last Name

* must provide value

Email Address:

* must provide value

What is your phone number?

Which campus are you attending?

* must provide value

UAMS Little Rock

UAMS Northwest Arkansas

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Which college are you enrolled?

* must provide value

Which degree are you working toward on the Northwest Arkansas Campus?

* must provide value

College of Medicine: Please select your level in the program

* must provide value

Year in Program-COPharm

* must provide value

Year in Program-MSiPH

* must provide value

1st year

2nd year

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Which program in College of Nursing are you enrolled in?

* must provide value

Which program in the College of Health Professions are you enrolled in?

* must provide value

Which program in the College of Public Health are you enrolled?

* must provide value

Which program in the Graduate School are you enrolled in?

* must provide value

Since you do not see your program listed, please try selecting "Graduate School" for your college. Many programs are taught primarily by a specific college, but are actually housed in the Graduate School. If you continue to have issues, please email Dr. Rikki Turner at rturner3@uams.edu and let her know your program and that you would like an appointment with a learning specialist.

Have you completed a Learning and Studying Skills Inventory (LASSI) assessment since enrolling at UAMS?

Yes

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Please upload a copy of your results here. If you are unable to do this, please bring a copy with you to your first appointment.

Upload file

After you submit this form, check your email for instructions on how to complete this 60 question assessment of your learning and studying skills. This should take you approximately 10 minutes to complete.

This information is extremely valuable to your learning specialist so it is important that you complete it before your appointment.

How would you like to meet?

In-person in Learning Specialist's office

Phone Call

Virtual (Zoom, Microsoft Teams, etc.)

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Which services are you interested in?
(based on availability)

* must provide value

Study Skills

Time Management

Test Anxiety

Test Prep

Test Taking

Reading

Notetaking

Concentration

Procrastination

Active Learning

Remediation

Writing - Academic

Writing - Resume/CV/Professional

Step 1 study plan (COM)

Step 1 test-taking (COM)

Step 1 study methods (COM)

Step 1 retake (COM)

Step 2 study plan (COM)

Step 2 test-taking (COM)

Step 2 study methods (COM)

Step 2 retake (COM)

Step 3 (COM)

Board exam/Professional certification exam

Request Peer Tutoring

Become a Peer Tutor

Individualized Study Plan as required by COM

Follow-up Meeting for ISP-COM

Other:

Is this a meeting required by your program?

Yes

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Which course are you being referred for?

You have selected one of our services provided by the Writing Center. Please submit your document to them via this form: Writing Center Submission

If you would still like to meet with a Learning Specialist for needs outside of writing, please continue with this intake form. If you are only needing writing assistance, you may exit the survey now.

How were you referred to the Educational and Student Success Center?

* must provide value

Self Referral

Faculty Referral:

College/Program Referral

Required by COM policy

Word of Mouth

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Please note: While we strive to provide individualized tutoring, a tutor may not be available for every subject area. If a tutor is not currently available, we will collaborate with your academic department to explore support options.

How you ever been diagnosed with any of the following? (Select all that apply)

ADHD or ADD

Dyslexia, Dysgraphia, and/or Dyscalculia

Anxiety, depression, and/or other mental illness

Autism Spectrum Disorder

Other (please specify):

I have never been diagnosed with a disability.

Have you ever used ADA accommodations (e.g., extended time, note taker, quiet testing environment)?

Yes

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Is English your first language?

Yes

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What language is your first language?

Have you ever used a peer tutor for a course in the past?

Yes

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Who was your peer tutor? For what course?

On average, how many hours of sleep do you get on a typical night?

less than 4

4 - 6

7 - 9

more than 9

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Do you currently feel that emotional or mental health concerns are affecting your academic performance?

Yes

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How well do you feel you belong in your current program?

Change the slider above to set a response

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Do you currently have a situation that takes your focus from your studies? If so, please describe.
(e.g. outside job, caregiving responsibilities, etc.)

Expand

You will be sent a separate link to complete the Learning and Study Strategies Inventory (LASSI). This will go to the email listed above. It is extremely important that you complete this assessment before your appointment with your learning specialist.

I understand and will complete the LASSI before my first session.

Academic History
Check every box that is a TRUE statement.

I have been diagnosed with a learning disability.

English is my second or additional language

I have been diagnosed with ADD or ADHD.

I have used ADA accommodations in the past.

I have used a peer tutor in a prior course.

I am easily distracted when I study.

I have gone to the Wellness Center or another counselor.

I get at least 7 hours of sleep.

When I do not understand a concept, I ask a student or professor for help.

My worrying interferes with my concentration when I am studying.

I have strategies to use when overwhelmed and/or stressed.

I have social system support.

I am currently struggling with emotional/mental issues as well.

I have never had to study to make good grades before.

Time Management
Check every box that is a TRUE statement.

It is hard for me to be consistent with a set study schedule.

I procrastinate frequently when I study.

I cram before an exam.

I can't find a way to balance my study time and my social life.

I use a planner/calendar to plan my study time.

I give myself enough time to study for an exam.

I plan on additional study time on subjects that are challenging to me.

Studying and Learning Habits
Check every box that is a TRUE statement.

I have a place where I study on a regular basis that is comfortable and without distraction.

I recognize the times of day when I'm most mentally alert.

It helps me to study with other students.

When I study, I concentrate on one subject for long periods of time (more than 1 hour) without a break.

I go to class, but I usually doodle, daydream, or fall asleep.

I don't study in an organized way, and I often worry about the next exam.

I know my learning preference(s).

My class notes are difficult to understand later.

I seem to pick out the wrong material to study in lectures, notes, and textbooks.

I don't look at my class notes after I've taken them.

When I get to the end of a chapter, I can't remember what I've just read.

I can't keep up with my reading assignments. I try to scan them before a test.

I read my text/PPTs, etc. before the lecture.

I change my reading speed when the text is difficult or unfamiliar.

I ask myself questions when I am studying to check for understanding.

I rewrite/retell the content in my own words when I am studying.

I actively participate in group work/discussions in class.

Examinations
Check every box that is a TRUE statement.

I do better on practical exams rather than written exams.

I often lose points on exam questions even when I know the material well.

It is difficult for me to understand what a question is asking.

I study enough for the exam, but when I take the test, my mind goes blank.

I usually run out of time when taking examinations.

When I start an exam, I answer the questions that I know first.

I go over my returned exams to learn from my mistakes.

I can narrow the answer down to two choices, and then I pick the wrong answer.

I change answers on my exams.

I use earplugs when I take a written exam.

I have a lot of test anxiety and my scores rarely reflect my true knowledge of the subject.

Survey Completion Timestamp

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

New Student Intake Form

You have selected one of our services provided by the Writing Center. Please submit your document to them via this form: Writing Center Submission

If you would still like to meet with a Learning Specialist for needs outside of writing, please continue with this intake form. If you are only needing writing assistance, you may exit the survey now.

Learning and Educational Background

Wellness and Mental Health

Belongingness and Extracurricular

You have selected an option that triggers this survey to end right now.