UTPB Career Counseling & Job Placement Services
Student Information Form
As soon as you complete this form, turn it in to the front desk staff. Thanks for completed this--it will enable
your counselor to better assist you by understanding some of your thoughts, concerns, and feelings.
Telephone # ________________________________
Today’s Date: ___________________
Name: ___________________________________________
Gender:
Last
Currently Enrolled at UTPB?
M
F
Age: ____
First
Y ____
Classification (circle one):
Freshman Sophomore Junior
N _____
Senior
Anticipated Graduation Date (mo/yr): __________
Grad Student
Alumni
Other
GPA: _____
College (Business, Lib. Arts, etc.): ______________
Major (accounting, French, etc.): _____________
Phone: ______________________ Email: (legibly) ____________________________________________
Would you like to be included in our job placement software system?
Primary Ethnicity (optional – circle one): African- American
International Multi-Racial Native-American
Y ____
N _____
Asian-American
What form of publicity prompted your visit today? (please circle one):
Academic Advisor
Family Member
Other UTPB Career Service Center
Flyer/Bulletin Board
Counseling Center
Friend
Email
Learning Center
Faculty
Newsletter
Caucasian
Hispanic
Orientation
Presentation by our staff
Walk by
Website
Other _______________
Briefly state your current career concern: _____________________________________________________
Please read the following statements and place a checkmark under the appropriate column regarding your
career concerns.
Yes No Unsure
1. I feel uncertain about which major to choose.
___ ___ ______
2. I am unclear about my career goals.
___ ___ ______
3. I want to talk with someone and/or gather information related
To my interest, skills, values, and personality.
___ ___ ______
4. I want to know more about the major and career tests.
___ ___ ______
5. I want to find information about certain occupations
___ ___ ______
6. I want to meet people in career areas that interest me.
___ ___ ______
7. I want to know more about internship opportunities
___ ___ ______
8. I want information on applying to graduate school.
___ ___ ______
9. I want my resume, cover letter, or graduation school statement critiqued
___ ___ ______
10. I want to learn more about interviewing for an internship.
___ ___ ______
11. I know what I want to do, but someone else thinks I ought
to do something else.
___ ___ ______
12. I need assistance in finding a part/full time job
___ ___ ______
Answer as many questions as you can in the time you have available. These questions will help you
thing more about your career concerns before you talk with a counselor.
1) If you had enough money to last a lifetime, what kind of work might you do? ___________________
___________________________________________________________________________________
2) Which 3-5 of these values is most important to you regarding your work?
___ Financial security
___ Location
___ Leadership
___ Creativity
___ Money
___ Moral Fulfillment
___ Helping others
___ Status/recognition
___ Pursuit of knowledge
___ Helping society
___ Free time/leisure
___ Challenge/adventure
___ Independence/being own boss ___ Competition
___ Enjoyment
3) If you would like your career to be different from your parents’ careers, how would you like it to be
different?
4) Who or what has had the most influence on your career up to this point and in what ways?
5) What aspects of your identity (e.g., ethnicity, family, first-generation college students, gender, race,
disability, religion, sexual identity) might influence your career? _________________________________
Major and career ideas
In the space below, take a few minutes to summarize your concerns at this time. If you are not sure
just describe what your best guesses are about your current concerns, options, ideas.
Example: I want to complete my education and then use my writing and verbal skills working somewhere,
but I’m not sure where and how I can do that.
Example: I don’t have much of an idea about what I want to do… and I’m not really sure how to begin.
Example: My parents have pretty strong ideas about what I should do and I’m not sure that I feel
comfortable with their ideas.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
As you work with a career counselor, other issues may surface necessitating that we refer you to other
resources. In those instances, we will refer you to the appropriate person or office. The content of your
session(s) will be held in the strictest confidence; the only exception is if there is a clear and present
danger that someone’s life maybe at risk. I understand the nature of the Career Exploration Center’s
counseling:
__________________________________________
Your Signature
__________________
Today’s Date