Emotional Evaluation 5783
Dear Parent,

Every student in Bnos Chomesh meets with a school counselor to help give her emotional support within the school environment.

In answering the questions below, honesty is key. Knowing what the underlying issues are helps us provide your
daughter with the best possible help and care. It also helps us to assess what help your daughter might need outside of the school environment.

Please rest assured that honest responses will not deter us from accepting your daughter into Bnos Chomesh;
rather it will enable us to work with your daughter as effectively as possible, as we will be well equipped and
prepared to connect with her.
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Email *
Students Name: *
Grade applying for: *
1. What lead you and/or your daughter to switch from her previous school to Bnos Chomesh? (list any emotional, academic, and/or social reasons) *
2. What are you/your daughter hoping to gain in Bnos Chomesh? (list any emotional, academic, and/or social/emotional goals) *
3. Is your daughter currently taking any medication? (Please list medications she takes regularly or took for 30 days or more within the past year; do not include short term regimens of antibiotics). *
**3. If the answer to #3 was yes, please indicate how long she has been on this medication:
4. Was your daughter taking any medication prior to a year ago? If so please list: *
5. Has your daughter been hospitalized for any accute mental health conditions? *
**5. If the answer to #5 was yes, please explain circumstances, duration of hospitalization, and recommendation when discharged.
**5. If the answer to #5 was yes, what was the follow up care?
If selected other- specify here.
6. Has your daughter ever received (past or current) a mental health diagnosis? *
**6. If the answer to #6 was yes, please check off the applicable boxes.
If selected other- specify here.
7. What supports does your daughter currently have for her mental health? *
8. Is there anything you or your daughter would like to share here that would be helpful for us to know? *
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