Hellstern Middle School Personal/Social Needs Assessment

The school counselors would like to ensure we develop and provide programs to meet the needs of our students. Please be totally honest with your responses. This will only be seen by the counselors. You have an option to leave your name if you would like to be involved in a small group. Again, this is confidential.

Please answer each question and answer it honesty. The last question gives you the option to leave your name.


         

       

Name (optional): 


A red asterisk (*) indicates required questions.

  1. I have been bullied at school this year.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I have bullied another student this school year.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I feel sad or depressed.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I feel anxious or nervous at school.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I have some attendance issues.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I am feeling sad over the loss of a loved one*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I am dealing with a divorce or separartion of a parent.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I get angry easily.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I am feeling sad because I have a parent who is in jail.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I have problems with cutting or harming myself.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I have an eating disorder.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I have issues focusing (attention issues).*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I am hungry when I come to school.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. I need to take food home with me over the weekends.*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. If you would like to be part of a small group regarding any of the above topics, please leave us your name.





Mrs. VanderBaan
Library Media Specialist
Hellstern Middle School
Springdale, AR