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Dearborn- SEL Student Screener Survey for Elementary Parents
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* Indicates required question
E-mail address
*
Your answer
Student's name
*
Your answer
Parent/Guardian's name
*
Your answer
Best phone number at which to contact parent/guardian
*
Your answer
Has anyone in your child's life had COVID-19?
*
Yes
No
Was your family affected by financial stress as a result of the pandemic (e.g., job loss, food insecurity, etc.)?
*
Yes
No
Prefer not to answer
Has your child experienced the death of someone close to them over the past 6 months?
*
Yes
No
If your child experienced grief due to a previous death, has the current COVID-19 Pandemic triggered the grief to resurface?
*
Yes
No
Have you noticed changes in how your child is managing emotions and using healthy coping skills over the last 6 months?
*
Yes
No
Unsure
If you answered yes to the previous question, what changes have you noticed?
Crying
Eating (increased or decreased appetite)
Sleeping
Withdrawing
Anger
Other:
In anticipation of school, is your child exhibiting signs of distress (e.g., excessive or limited sleep, separation anxiety, or physical symptoms such as stomach ache, headache, etc.)?
*
Not at all
Sometimes
Often
How concerned are you about your child's social/emotional well-being at this time?
*
Not concerned
A little concerned
Somewhat concerned
Mostly concerned
Very concerned
Required
When your child is stressed, what are the actions that help him/her?
*
Physical activity (walking, biking, dancing, playing basketball, etc)
Talking
TV/Gaming breaks
Breathing Techniques
We have not yet figured out what is most effective
Other:
Required
Has your child stayed connected with friends/peers over the past 6 months (through social media, gaming, outdoor activities, etc.)?
*
Not at all
Sometimes
Often
What, if any, additional mental/emotional health support do you think your child will need upon returning to school in-person?
Your answer
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