5th - 8th Grade Survey 2016-2017 Holy Rosary
As your school counselor for this school year, I would like to ensure that I am developing and providing programs that meet your needs. Please read each statement and mark the most appropriate answer choice for you. Please be completely honest in your response. Your answers will remain confidential.

Thank you,
Lani Thomas

Last Name *
First Name *
Grade *
I need help with the following personal/social concerns: *
I don't need help at all
I need help
Making friends
Handling teasing or being bullied
Dealing with peer pressure
Improving communication
Dating or relationship issues
Concerns about drug or alcohol use
Improving self-esteem or self-confidence
Getting along with family members
Getting along with friends or other students
Feeling sad or depressed
Thoughts of hurting myself
Thoughts of suicide
Grief over the loss of a loved one
Parental divorce or separation
Dealing with anger
Feeling anxious or stressed
Violence or harassment
Finding a place to live
Purchasing food or other items
Difficulty eating
Difficulty sleeping
I need help with the following academic concerns: *
I don't need help at all
I need help
Being organized
Managing my time
Improving my study skills
Reducing test anxiety
Improving test-taking skills
Asking teachers for help
Please indicate how much you agree with the following statements: *
Strongly Disagree
Strongly Agree
I like coming to school
I feel safe at school
I have good attendance
I feel like my teachers care about me
Please list any concerns below
I am interested in participating in a small group related to: *
I would like to schedule an appointment with my counselor *
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