YOU and US
Hi! Welcome back to school! The information you will share here is confidential between YOU and US (the school counselors). It will help us support you and help with your needs during the school year.
Thanks, Mrs Herbert and Ms Anderson.
Grade Level *
Name (First and Last) *
Who do you live with? (Examples: mom, dad, grandparents, brothers, sisters, guardians, foster parents, aunts, uncles, friends, other people) *
How do you spend your time after school? (example: at home, clubs, sports, youth groups, teams, hobbies) *
Has there been an experience in your life that that you would like to share with the counselors, good or bad? If yes, please share below. *
What's your favorite Movie OR Book and why? *
If there is something else you would like the counselors to know about you, please write it here. *
What do you have access to at home? Check the box next to any that apply *
Where are you currently living? Please check one. *
If you have concerns about any or all of the below areas, please check the box. You may check more than one. *
Student Needs Assessment
Please rate how interested you personally are in the following services:
Individual Counseling *
Not Needed
Highly Needed
Group Counseling *
Not Needed
Highly Needed
Would you like more information on mental Health: Like Depression and anxiety and how to cope? *
Not Needed
Highly Needed
Additional Comments/Concerns:
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