Emotional Health Survey
COMPLETE ONE SURVEY PER CHILD WITH CHILD INPUT.
PLEASE USE THIS AS A TOOL TO HELP DETERMINE IF YOUR CHILD MAY BE EXPERIENCING ANXIETY/OTHER MENTAL HEALTH CHALLENGES THAT ARE BEYOND NORMAL LEVELS. IF YOU FEEL YOU CHILD'S ANXIETY LEVELS ARE ABOVE AVERAGE OR THEY ARE EXPERIENCING OTHER MENTAL HEALTH CHALLENGES PLEASE REACH OUT TO MS. NESBIHAL TO DISCUSS COUNSELING AND OTHER AVAILABLE RESOURCES.

anesbihal@unionbeachschools.org

Due to COVID-19 anxiety levels and mental health illnesses have substantially increased in children and adults. We would like to get a gauge on how your child is dealing with all the uncertainty his pandemic has brought to us. We want to collect as much data as possible on the overall anxiety level of students to help address the needs of all students on a school-wide and individual level.

Anxiety is a normal reaction to stress and can be beneficial in some situations. It can alert us to dangers and help us prepare and pay attention. Anxiety disorders differ from normal feelings of nervousness or anxiousness, and involve excessive fear or anxiety.

Anxiety disorders can cause people into try to avoid situations that trigger or worsen their symptoms. Job performance, school work and personal relationships can be affected.

In general, for a person to be diagnosed with an anxiety disorder, the fear or anxiety must:
1. Be out of proportion to the situation or age inappropriate
2. Hinder your ability to function normally

There are several types of anxiety disorders, including generalized anxiety disorder, panic disorder, specific phobias, agoraphobia, social anxiety disorder and separation anxiety disorder.

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. It affects how you feel, think and behave and can lead to a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and sometimes you may feel as if life isn't worth living.

Depression is more than just a bout of the blues, depression isn't a weakness and you can't simply "snap out" of it. Depression may require long-term treatment. But don't get discouraged. Most people with depression feel better with medication, therapy or both.

Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.

Most people who go through traumatic events may have temporary difficulty adjusting and coping, but with time and good self-care, they usually get better.



Student's Name?
Student's Grade Level?
Student's Homeroom Teacher?
Student's Method of Learning?
Clear selection
Rate the level of anxiety associated with the following situations.
Interacting with others outside of close family or friends .
No Anxiety
Extreme Anxiety
Clear selection
Leaving the house for routine trips (i.e food shopping etc.).
No Anxiety
Extreme Anxiety
Clear selection
Going to school.
No Anxiety
Extreme Anxiety
Clear selection
Touching door handles, shopping carts, or other items from outside the home .
No Anxiety
Extreme Anxiety
Clear selection
Encountering someone without a mask on or a mask under their nose/not worn properly.
No Anxiety
Extreme Anxiety
Clear selection
Have you utilized any coping or calming strategies when these feelings arise?
Clear selection
If so, which ones did you find helpful?
Have you noticed a change in your child's mood?
Clear selection
If yes, explain.
Do you notice yourself withdrawing from activities that can be done safely while maintaining social distancing?
Clear selection
Have you noticed a decrease in your communication with friends?
Clear selection
Have you noticed any behavior that is atypical for your child? (easily angered, on edge, tired, easily overwhelmed, sad, disrespectful, insomnia or sleep disturbances)
Clear selection
If yes, explain.
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