Name: _________________________________________________________ Date: ______________________

Local address: ___________________________________ Zip: ___________ Telephone:__________________

Major: _________________________________________ E-mail: ________________________________

Course(s) for which you are bringing in a paper: __________________________________________________

Instructor:__________________________________ Department: ____________________________________

Freshmen ______ Sophomore _______ Junior ________ Senior _______ Grad _______ Special             *********************************************************************************************************************************************

Did your professor refer you to the Writing Center individually? Yes ______ No ______  (Check one.)

Did your professor recommend the Writing Center to the whole class? Yes ______  No ______ (Check one.)

IF WE HAVE RECEIVED A REFERRAL FORM FROM YOUR INSTRUCTOR, A SUMMARY OF WHAT WAS DISCUSSED IN YOUR TUTORING SESSION WILL BE SENT TO YOUR INSTRUCTOR. IF WE DO NOT HAVE ONE, NO REPORT WILL BE SENT UNLESS YOU REQUEST US TO DO SO.

Do you wish a report to be sent to your instructor if we have not received a referral form? Yes ______     No          ************************************************************************************************************************************************

I want to improve my writing skills in the following areas:

_____ pre-writing, invention strategies

_____ organization

_____ development

_____ thesis statement

_____ style (i.e., sentence structure, variety, wordiness, etc.)

_____ sentence fragments, comma splices, run-together sentences

_____ subject-verb agreement

_____ pronoun agreement/reference

_____ punctuation

_____ spelling

_____other (Please specify.) ______________________________________________________

If you wish, tell something about yourself and what you hope to accomplish by working in the writing center. Strengths? Weaknesses? Goals?