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How are you doing?
For UTVA Students:
Tell us how you are doing. You may need to ask a parent for help with some questions.
*This form will be sent to the school counselor. Thank you!
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First Name:
*
Your answer
Last Name:
*
Your answer
Teacher:
*
Your answer
Grade:
*
Choose
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
FEELINGS - Today I am feeling:
HAPPY
SAD
WORRIED
ANGRY
LOVED
BORED
TIRED
EXCITED
OVERWHELMED
CALM
Other:
Clear selection
Tell us about something GOOD that happened today:
Your answer
Did you have any concerns or problems today?
Yes
No
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If you had a problem today, did you STOP and identify your FEELING?
Yes
No
Clear selection
And then did you use a COPING SKILL to calm down?
Yes
No
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COPING SKILLS - If you haven't tried a coping skill, the following ideas may help you feel better! Pick one skill that you want to use to calm down and manage your feelings.
Choose
DEEP BREATHING
COUNT TO 100
COLOR PICTURES
POSITIVE SELF TALK
SAY POSITIVE AFFIRMATIONS
GET A HUG
LISTEN TO MUSIC
CREATE ART
READ A BOOK
PRACTICE BEING CALM
TAKE A BATH
PLAY WITH YOUR PET
CREATE MUSIC
WRITE IN YOUR JOURNAL
TALK WITH SOMEONE
TAKE A NAP
EXERCISE
TAKE A WALK
LAUGH
DO SOMETHING FUN
WRITE A POEM
VISUALIZE A PRETTY PLACE
WATCH A FUNNY VIDEO
COMPLIMENT SOMEONE
EAT A SNACK
SING THE ALPHABET
STRETCH YOUR ARMS AND LEGS
WRITE 3 THINGS YOU LOVE ABOUT YOU
SQUISH A STRESS BALL
DO JUMPING JACKS
PUT ON FUZZY SOCKS
DO A PUZZLE
THINK OF SOMETHING HAPPY
HUG A PILLOW
BLOW BUBBLES
TOSS A PEBBLE IN A POND
FINGER PAINT
BOUNCE A BALLOON
LIST 5 THINGS YOU'RE GRATEFUL FOR
SHOOT BASKETBALL HOOPS
After using a coping skill, how do you feel?
Not Better At All
1
2
3
4
5
So Much Better!
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If you're not feeling better, would you like to set up a check-in visit with the school counselor?
Yes
No
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If yes, what would you like to talk about?
*The School Counselor will respond to you through your email to check in.
Your answer
Submit
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