FRHS Wellness Center Log Check-Out Form
Date *
MM
/
DD
/
YYYY
Student ID *
Your answer
Grade *
Please enter the grade level of the student
Duration of WC Visit *
Enter the length of time the student spent in the wellness center in minutes.
Your answer
Interventions *
Select "yes" or "no" to indicate which interventions were used during this visit to the WC.
yes
no
Breathing exercise
Check in with staff
Workout equipment
Quiet space to read
Quiet space for art
Quiet space with headphones or music
Hands on stress management tools
Check out ranking *
Please enter the student's self ranking at check out.
Extremely anxious/upset/escalated
Calm, focused
Submit
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