Student and Family Wellness Form
Please answer all questions. Responses will be received immediately and will reach out within 24 hours.
Email address *
Name of person filling out this form? *
Student First and Last Name *
School *
Student Grade? *
Best phone number to reach you? *
Do you have access to 3 meals a day? *
How many children live in your house? *
Are you familiar with our food drive program? *
In the last two weeks have you felt a lot of anxiety? *
Is this anxiety caused more by school or home? *
Brief description of what is causing the anxiety *
In the last two weeks have you had any thoughts of harming yourself or others? *
In the last year have you seen your doctor? *
In the last year have you been to the dentist? *
In the last year have you gone to see an eye doctor? *
Are you in need of resources to help with monthly payments? (Rent, heat, electric, etc.?) *
A copy of your responses will be emailed to the address you provided.
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