Mental Health Survey
Since the closure of school in March, has your child experienced any of the following during the school closure? (Check all that apply)
Difficulty falling or staying asleep
Difficulty eating
Expression of worry in general about things that were not problematic before
Expression of worry about return to school in particular
Feelings of sadness
Feelings of hopelessness or despair
Difficulty relating to others (consider age appropriate expectations)
Difficulty returning to a normal school routine (waking, adjusting to new rules, different set of expectations)
Has your family experienced any of the following as a result of the COVID-19 closures? (Check all that apply)
Loss of job
Lack of food for three meals
Health concerns
Depression or mental health concerns
Housing concerns
Lack of childcare support
Not enough computers
Lack of computer knowledge/experience to utilize technology for children
Lack of support for student’s academic difficulties
Inability to pay cell phone bills
Unable to support child(ren)
The death of a loved one or close acquaintance
The child has witnessed serious illness
One or both parents/guardians are essential workers who spend significant time away from home
No hardships
Other:
How concerned are you about your child’s social-emotional well-being?
Not at all concerned
Slightly concerned
Somewhat concerned
Quite concerned
Extremely concerned
Clear selection
Is there anything else you would like to share about your child’s social-emotional well-being?
Your answer
Did you observe or identify an area of social/emotional strength and/or weakness new to your child?
Your answer
How would you describe your child’s current mental state?
Your answer
What coping strategies did your child use during school closure?
Your answer
Would you like to talk privately with an administrator or counselor from your child’s school about your child’s social-emotional well-being or academic needs?
Yes
No
Clear selection
If you selected “yes,” please fill in the following information: Child’s First and Last Name, Child’s Grade, Your First and Last Name, Phone Number and Email.
Your answer
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