Natural Helpers Report Form
Please complete this form each time you have a situation where you work through a problem or situation with a friend, classmate, or relative.
Name of Natural Helper
Name of person receiving help
Type "anonymous" if this person wishes to remain anonymous
Describe this helpful encounter
Have you referred this situation to an adult?
What is the name of the adult referred?
How much do you feel you helped this person with this specific situation?
1-not at all
3 -I helped
4-I helped a lot
Does this interaction encourage you to continue to help people?
1-I don't want to help again
2-I may help again
3-I will help again
4-I am excited to help again
5-I am seeking ways to always help others
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