What My Counselor Should Know About Me

Please, complete this survey about yourself as best you can. Your counselor, Mrs. Boeve, is the only person that will see your results. Results from this survey may be used to assess the counseling program, see if there is interest in forming counseling groups, and self referrals for counseling.
Name: 


A red asterisk (*) indicates required questions.

  1. The people who live with me in my house are (list all)*


  1. Choose the answer that applies to you:*
    I only live at one house
    I also live at another house sometimes


  1. If you answered "I also live at another house sometimes" in Question 2, please, list the people that live at your other house below:


  1. An adult I really trust to talk to is (check all that apply)...*
    Mom
    Dad
    Older brother or sister
    Neighbor
    Teacher
    My friend's parent(s)
    Grandma or Grandpa
    A family member
    Principal
    Counselor
    Coach
    My boss
    Other
    No One


  1. The academic subject that is most challenging for me is*
    Science
    Math
    Social Studies/ History
    Reading
    Language Arts


  1. The academic subject that is least challenging to me is*
    Science
    Math
    Social Studies/ History
    Reading
    Language Arts


  1. My favorite thing about school is...*


  1. Focusing on my work at school is...*
    Challenging
    Sometimes easy, Sometimes hard
    Pretty easy


  1. Getting my homework done is...*
    Challenging
    Sometimes easy, Sometimes hard
    Pretty easy


  1. Sometimes I might need help with or need someone to talk to about (check all that apply to you)...*
    Friendship problems
    Being a "Good Sport"
    Family problems
    Not enough money in my family
    People in my family fighting
    Worrying
    Someone in my family being sick
    Someone I know using drugs/alcohol
    Not getting to see a family member
    Being safe
    Being bullied
    Being really sad or down
    Someone dying
    Loneliness
    School work being hard
    Being different
    Someone encouraging me to use drugs/alcohol
    Wanting more challenging work
    Being hurt physically
    Being hurt with words
    Self Harm/ Self Injury (cutting, burnning, hitting self, ...)
    Suicidal Thoughts
    Dating Abuse (Emotional, Verbal, and/or Physical)
    Other
    None


  1. I would like to speak with a counselor at school privately.*
    Yes
    No


  1. I am interested in being a part of a small counseling group with other students going through the same things as me.*
    Yes
    No


  1. I have spoken with Mrs. Boeve ...*
    One time
    Occassionally
    Never


  1. I have met with a counselor before (either Mrs. Boeve, a counselor at a different school, an outside counselor, ...)*
    One time
    Occassionally
    Never


  1. I am worried about another student at Canton middle school who is struggling with (check all that apply)...*
    Self Harm/ Self Injury (cutting, burning, hitting self, other)
    Using drugs and/or alcohol
    Family Issues
    Friendship Issues
    Dating Abuse (Emotional, Verbal, and/or Physical)
    Academic Issues
    Depression
    Anxiety
    Low Self Esteem
    Anger Issues
    None


  1. IMPORTANT:
    If you checked any answers for Question 17, please, list the name of the student(s) you are concerned about below.
    NOTE: Your name will be kept confidential by Mrs. Boeve.


  1. Something that I am good at is...*


  1. Something you should really know about me is...*





Mrs. Nolte
Ms/HS English Teacher
De Smet Middle and High School
SD