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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* Required
Email
*
Your email
What is your first name?
*
Your answer
What is your last name?
*
Your answer
Date
*
MM
/
DD
/
YYYY
Time
*
Time
:
AM
PM
What grade are you in?
*
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Required
How are you feeling
*
Happy
Sad
Confused
Stressed
Angry
Anxious/Nervous
Other
What calm down skills did you try?
Take deep breaths
Draw a picture
Count to 10
Listen to music
Dance
Excercise (jumping jacks, push ups, job in place, etc)
Read a book
Color a picture
Relax
After using that skill, how do you feel?
Not better at all
1
2
3
4
5
So much better
Clear selection
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
Required
Add your contact information if you would like me to follow-up with you, (Email and/or phone number).
*
Your answer
Thank you! I will be contacting you soon.
You are worth it!
Send me a copy of my responses.
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