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!
Sign in to Google
to save your progress.
What is your first name?
What is your last name?
What grade are you in?
How are you feeling
What calm down skills did you try?
Take deep breaths
Draw a picture
Count to 10
Listen to music
Excercise (jumping jacks, push ups, job in place, etc)
Read a book
Color a picture
After using that skill, how do you feel?
Not better at all
So much better
What would be helpful for you right now?
Individual Counseling Check-In
I need some ideas on how to handle my stress
I need a some ideas on how to solve a problem
I need to talk to you
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!
Send me a copy of my responses.
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This form was created inside of Pilot Rock School District.