GATES Student Needs Assessment
Please indicate whether the following things are CONCERNS for you.
If you have additional comments, please leave them in the "other" box.
Dealing with change *
Required
Controlling your anger *
Required
Failing classes *
Required
Fighting *
Required
Having a personal problem with drugs or alcohol *
Required
Divorce or separation in your family *
Required
Death of a loved one *
Required
Loss of a close friend or relationship *
Required
Getting along with others *
Required
Being bullied *
Required
Being harassed *
Required
Pregnancy *
Required
Stress *
Required
Hurting/cutting yourself *
Required
Thoughts of ending your life *
Required
Feeling sad or depressed *
Required
Rumors or gossip *
Required
Dropping out of school *
Required
Eating disorders *
Required
Living away from parents *
Required
Physical abuse *
Required
Sexual abuse *
Required
Fear of making mistakes *
Required
School attendance *
Required
Test anxiety *
Required
Drug or alcohol abuse by family members *
Required
Low self-esteem *
Required
Maintaining healthy relationships *
Required
Neglect by family *
Required
Difficulty paying attention *
Required
Homelessness *
Required
Poverty (not having enough money for food or other essential items) *
Required
Violence in the home *
Required
Violence in a relationship *
Required
Study skills *
Required
Having a family member in prison *
Required
Social anxiety *
Required
Do you have an adult outside of school you trust? If yes, what is their name?
Your answer
Do you have an adult at GATES you trust? If yes, what is their name?
Your answer
Do you have any other concerns that were not listed? If so, please share them below.
Your answer
What is your first name? *
Your answer
What is your last name? *
Your answer
What gender do you identify with?
What grade are you in? *
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