Individual Student Needs Assessment
Name: *
Your answer
Grade *
These are the things that concern me...about myself: *
Required
These are the things that concern me...about friends: *
Required
These are the things that concern me...about school: *
Required
These are things that concern me...about home/family: *
Required
Most of the time I feel...(happy, sad, excited, angry, depressed, etc.) *
Your answer
Here's something else I would like to share...(anything that you would like me to know about you; it can be happy or sad or both)
Your answer
OPTIONAL: I would like to talk to the counselor about something that is bothering me...
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