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
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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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