Wellness Center Check-In Form
Please complete the short survey below if you would like to check-In with Mrs. Doherty!


Welcome to Mrs. Doherty's Wellness Center check-in!  If you would like to connect please answer just a few questions in order to help me better understand your feelings and needs.

Thinking of you!

Mrs. Doherty
helen.doherty@pilotrocksd.org


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Email *
What is your first name? *
What is your last name? *
Date *
MM
/
DD
/
YYYY
Time *
Time
:
What grade are you in? *
Required
How are you feeling *
What calm down skills did you try?
After using that skill, how do you feel?
Not better at all
So much better
Clear selection
What would be helpful for you right now? *
Required
Add your contact information if you would like me to follow-up with you,  (Email and/or phone number). *
Thank you!  I will be contacting you soon.
You are worth it!
Submit
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