Social/Emotional Assessment
Please fill out this information accurately and to the best of your ability. This information will be kept confidential and you will remain anonymous.

Answer each statement and check how true it is.

I need help with the following PERSONAL concerns:
Strongly Agree
Neither Agree nor Disagree
Strongly Disagree
Dealing with peer pressure
Dating or relationship issues
Concerns about alcohol and/or drug use
Helping myself (self-confidence, self-image)
Handling teasing or being bullied
Feeling sad or depressed
Feeling suicidal
Grief over the loss of a loved one
Parental divorce or separation
Dealing with anger
Feeling stressed
Feeling anxious or irritable
I have experienced the following:
The biggest obstacles I am facing in high school are:
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