Counselor Check In - How are you doing?

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Welcome friends. I would love to hear how you're doing today. Please answer as many or as few of the questions below. The more, the better! Your answers are private to Mr. P only.

********************************************************************************************
Please be aware that Mr. P only checks these responses during his normal work hours
from Mondays-Fridays from 7:30am to 4:00pm.
********************************************************************************************

Please send me an email (patrickphanthanusorn@iusd.org) if you have any other thoughts to share. Stay healthy. Stay Safe. And Stay Weird. @(*0*)@

What is your first and last name? *

What zone are you in today?

Blue

Green

Yellow

Red

Zone:

Clear selection

Why do you feel in that zone today? Tell me about it

How is everything at home?

Not good at all -- I need a check in

Home is great!!!

Clear selection

What is one thing you've done today that you enjoy?

Did you have any problems today?

Yes

Clear selection

Here are coping skills you can use if you are having a rough time. Let me know which ones you tried.

Take deep breaths

Draw a picture

Count to 10

Listen to music

Dance

Talk about it

Exercise

Read a book

Color a picture

Relax

Other:

After using that coping skill, how do you feel?

Not better at all.

So much better!

Clear selection

Would you like to meet with me?

Yes, I would like to schedule a check-in.

No, thank you. I am good for now!

Clear selection

Is there anything else you would like to share with me or tell me about?

Thank you for filling this out!!!

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Irvine Unified School District.

Does this form look suspicious? Report

Forms