WWCSMS Student Check-in
Hi there!  Ms. Sara wants to know how you are doing!  
You can fill out this form as many times and as often as you wish.  
Daily or weekly or whenever you feel like it!  You MATTER to me!
Sign in to Google to save your progress. Learn more
Student First & Last Name: *
If you are a parent/guardian filling this form out for your child, what is your name?
Grade: *
Teacher: *
I am feeling (Check all that apply) *
Required
Are you getting enough sleep?  How are you sleeping? *
Not sleeping well/ just a little bit of sleep
I am sleeping great! I am getting at least 8 to 10 hours of sleep every night.
If you have brothers, sisters, cousins, or other kids living with you, are you using Kelso's Choices to solve problems? *
Captionless Image
What are some things you are doing to stay busy? *
Use the emojis to help answer the following questions.
How are things at home? *
Very Hard
Very Easy!
How are things overall? *
Very Hard
Very Easy!
Hey, if you're interested., I'll be running a few counseling groups and interactive social groups. Would you be interested? *This question is not required*
Clear selection
Please let me know about any questions, concerns, or worries you may have right now.
Would you like me to check in with you at some point during the school day? *
Is there anything else I can do to support you? Or anything else you want me to know?
**Important Reminder**
This form is for non-emergencies only. If it is an emergency (thoughts of harming yourself or others), do NOT email your School Counselor. Call 911 or text HOME to 741741 or call the National Suicide Prevention Line: 1-800-273-8255. If you have immediate concerns for a child's safety and/or believe they are victims of abuse, please make a DCFS report or call 911.

Please understand that confidentiality cannot be guaranteed via phone conferences. We will make every effort to ensure a confidential conversation, and as always, we will notify the appropriate persons if any of the following come up in our conversation:
1. Someone is hurting you.
2. You want to hurt someone.
3. You want to hurt yourself.
4. You give me permission to share with another trusting adult.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of LANCASTER SCHOOL DISTRICT. Report Abuse
Google Forms