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Jefferson Elementary Mental Health Team Family Needs Assessment
Jefferson Elementary School
2020-2021
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* Indicates required question
Parent/Guardian Name
*
Your answer
Student(s) Name
*
Your answer
Phone Number
Your answer
E-mail
Your answer
What is your relationship with this student?
Parent
Guardian
Foster Parent
Grandparent
Other:
Clear selection
Has your family experienced any life changing events since March of 2020? (Ex. loss of family member, job loss, divorce, etc.)
Your answer
Has there been a major change in your child's mood or behavior since March of 2020?
Yes
No
Clear selection
If yes, please explain.
Your answer
Is your child/family receiving any support services due to life changes or events? (Ex.Counseling, community resources, etc.)
Yes
No
Clear selection
If yes, what supports?
Your answer
Would you like someone from our Mental Health & Wellness team to reach out to you for resources/support?
Yes
No
Clear selection
Would you like your child(ren) to be added to our Mental Wellness Google Classroom? This is optional and will provide students with mental health resources and access to tools for social/emotional learning.
Yes
No
Clear selection
Any other comments you feel like we need to know about your student or family?
Your answer
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