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School Counseling Program Needs Assessment
All counseling programs are designed to help children reduce barriers to learning.
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* Indicates required question
Email
*
Your email
Student Name
Your answer
Parent Name
Your answer
Grade
Kinder
1st
2nd
3rd
4th
5th
Other:
Clear selection
Student Needs Assessment
I have figured out ways to connect with my friends during Covid-19.
Strongly disagree
1
2
3
4
5
Strongly agree
Clear selection
I need help building and maintaining friendships.
Strongly disagree
1
2
3
4
5
Strongly agree
Clear selection
I am able to complete my school work during online learning.
Strongly disagree
1
2
3
4
5
Strongly agree
Clear selection
I need help with focusing on online learning.
Strongly disagree
1
2
3
4
5
Strongly agree
Clear selection
I need help with independent learning time.
Strongly disagree
1
2
3
4
5
Strongly agree
Clear selection
I am able to handle big feelings that come up during online learning.
Strongly disagree
1
2
3
4
5
Strongly agree
Clear selection
I need help with big feelings that come up during online learning.
Strongly disagree
1
2
3
4
5
Strongly agree
Clear selection
I have a strong connection with at least one adult at school. Who? Please enter any adults you feel supported by at Alpine Elementary.
Your answer
If you could tell the school counselors one thing about you, what would it be?
Your answer
Parent Needs Assessment
I would like to request my child to be seen by the counselor. (This does not guarantee counseling services but if you select 'yes' we will follow up with you about your concerns and counseling options for your student.)
Yes
No
If you selected 'yes' above, please briefly explain your concern. We will connect with you within 48 of receiving your request.
Your answer
Please put a check by any of these issues that are current and may be interfering with your child’s learning:
Friendship/social skills/Self-Esteem
Anger management/conflict resolution/emotional regulation
Grief /loss
Divorce/family change/incarceration
Anxiety
Study skills/lack of motivation in school
Other:
If you selected "Other" above, please explain below:
Your answer
What topics would you like to learn more about?
Friendship/social skills/Self-Esteem
Anger management/conflict resolution/emotional regulation
Grief /loss
Divorce/family change/incarceration
Anxiety
Study skills/lack of motivation in school
Other:
If you selected "Other" above please explain below:
Your answer
If you would like to learn more about any of the above topics, how would you like to receive this information:
Newsletter
Counseling Website
Small parent discussion group with Principal and/or Counselors
Parent Information Night
Other:
Would you like resources or assistance to support your student's learning? Check all that apply.
Technology hardware or internet access
Navigating Schoology/SeeSaw/Other Learning Applications
Setting up my child's daily schedule/physical workspace
Monitoring my child's progress
Basic Needs (food, housing, healthcare, behavioral health support)
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