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
KLOCKNER ELEMENTARY SCHOOL
Grade level of the student
Name of the person completing this form:
Relationship of the person completing the form to the student:
Self (if you are the student completing the form)
Preferred contact of person completing this form
Ex. Cell number: 555-555-5555 or Email:
1. Has the student experienced any significant trauma in the past 2 years (ie: loss of a loved one, serious illness, family changes)
Yes and the student is connected to services within the community to help them cope with this trauma.
Yes and the student is NOT connected to services within the community to help them cope with this trauma.
2. How would you describe your family’s food situation?
We are okay with food right now.
We need assistance with providing food for our family.
3. How would you define the student’s current social or emotional well-being?
The student is coping well.
The student is struggling with his/her social-emotional well-being.
I am extremely concerned about the student’s social-emotional well-being and coping skills.
4. Is the student struggling with his/her social-emotional well-being?
Yes, but things are under control.
Yes, and I am concerned. (Please elaborate at the bottom or contact your school counselor)
5. Did the student engage in social activities (virtual or in-person) with peers his/her age over the summer?
Not at all.
6. Are you in a stable housing situation?
We are in a temporary housing situation.
Our family is experiencing homelessness.
7. Have there been any significant changes in your family recently?
Loss of a family member or friend.
Loss of job/income.
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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This form was created inside of Hamilton Township School District.