Klockner Back to School Wellness Survey
Welcome back students and families! As we enter a new and different school year, we want to be sure we are supporting the well-being of all of our students.

The purpose of this form is to gather information about each student's social-emotional wellness. This information will be shared with your school's Student Support Team, made up of an administrator, school counselor, school nurse, and few other staff members from the school who care deeply about how each student is coping. This information will help us identify appropriate levels of support for each student as we transition back to school. Any information shared on this form is confidential* and will only be read by the Student Support Team at your school.

All students will have a Support Mentor and will receive universal supports through social and emotional and wellness activities. Student Support Teams will contact students and families within the first few weeks of school if this survey indicates a need for a higher level of support. If you have any questions or concerns, please contact the school counselor assigned to you/your child.

*Any information shared regarding imminent danger or harm to self or others cannot be kept confidential and must be reported as per state law.

Forms may be completed by parent/guardians or self-reported by students. Please complete one form for each student in your household.
First name of student *
Last name of student *
School name *
Grade level of the student *
Name of the person completing this form: *
Relationship of the person completing the form to the student: *
Preferred contact of person completing this form *
Ex. Cell number: 555-555-5555 or Email: example@gmail.com
1. Has the student experienced any significant trauma in the past 2 years (ie: loss of a loved one, serious illness, family changes)
Clear selection
2. How would you describe your family’s food situation?
Clear selection
3. How would you define the student’s current social or emotional well-being?
Clear selection
4. Is the student struggling with his/her social-emotional well-being?
Clear selection
5. Did the student engage in social activities (virtual or in-person) with peers his/her age over the summer?
Clear selection
6. Are you in a stable housing situation?
Clear selection
7. Have there been any significant changes in your family recently?
Clear selection
8. Please provide additional information if there anything specific you think we should know, or you would like to elaborate on the questions above.
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