Dearborn- SEL Student Screener Survey for Elementary Parents
E-mail address *
Student's name *
Parent/Guardian's name *
Best phone number at which to contact parent/guardian *
Has anyone in your child's life had COVID-19? *
Was your family affected by financial stress as a result of the pandemic (e.g., job loss, food insecurity, etc.)? *
Has your child experienced the death of someone close to them over the past 6 months? *
If your child experienced grief due to a previous death, has the current COVID-19 Pandemic triggered the grief to resurface? *
Have you noticed changes in how your child is managing emotions and using healthy coping skills over the last 6 months? *
If you answered yes to the previous question, what changes have you noticed?
In anticipation of school, is your child exhibiting signs of distress (e.g., excessive or limited sleep, separation anxiety, or physical symptoms such as stomach ache, headache, etc.)? *
How concerned are you about your child's social/emotional well-being at this time? *
Required
When your child is stressed, what are the actions that help him/her? *
Required
Has your child stayed connected with friends/peers over the past 6 months (through social media, gaming, outdoor activities, etc.)? *
What, if any, additional mental/emotional health support do you think your child will need upon returning to school in-person?
Submit
Never submit passwords through Google Forms.
This form was created inside of Dearborn Public Schools. Report Abuse