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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