JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
BCHS YSC Student Needs Assessment 15-16
Sign in to Google
to save your progress.
Learn more
Do you currently live with:
Parents
Grandparents
Other Relative
Friends
On your own
Other:
Clear selection
Do you or your family need assistance or info on Dental, vision, or Health Services?
Yes
No
Clear selection
Do you or your family need assistance or info on Anger/Conflict management?
YEs
No
Clear selection
Do you or your family need assistance or info on Pregnancy or Parenting?
Yes
No
Clear selection
Do you or your family need assistance or info on suicidal thoughts for yourself or concern for a friend?
Yes
No
Clear selection
Do you or your family need assistance or info on self-esteem?
Yes
No
Clear selection
Do you or your family need assistance or info on stress management?
Yes
No
Clear selection
Do you need to talk to someone about private issues?
Yes
No
Clear selection
Do you need to talk to someone about the death of a friend or family member?
Yes
No
Clear selection
Do you or your family need assistance with clothing?
Yes
No
Clear selection
Do you or your family need assistance with food at home?
Yes
No
Clear selection
Do you or your family need assistance with utilities (water, electric, gas)?
Yes
No
Clear selection
Do you or your family need assistance with health insurance?
Yes
No
Clear selection
I feel pressure from others to take drugs.
Yes
No
Clear selection
I use tobacco products regularly.
Yes
No
Clear selection
I have had problems at school/court with drugs/alcohol.
Yes
No
Clear selection
I use marijuana regularly.
No
Yes
Clear selection
I use prescription drugs that are not mine.
Yes
No
Clear selection
I use other illegal drugs regularly.
Yes
NO
Clear selection
Do you need tutoring assistance?
Yes
No
Clear selection
Do you need information on career options?
Yes
No
Clear selection
I am confident in filling out a job application.
Yes
No
Clear selection
I am confident in my ability to write a resume.
Yes
No
Clear selection
I am confident in my interviewing skills.
Yes
No
Clear selection
I know how to apply for college.
Yes
No
Clear selection
I know how to complete my FAFSA.
Yes
No
Clear selection
To be able to make decisions about a future career or college, I need......
Your answer
What do you consider the MOST important issue affecting students at BCHS ?
Your answer
Would you like to see more activities after school or in the summer (other than sports) offered at BCHS? If so, what do you feel is most needed?
Your answer
Name (optional)
Your answer
Grade
9
10
11
12
Clear selection
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of Bullitt County Public Schools.
Report Abuse
Forms
