22-23 4th Grade Student Needs Survey

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This form is for the school counselor to collect information to use to guide programming this school year. Please take your time and answer questions honestly. Raise your hand if you have any questions about any part of this. If you are interested in a small group counseling, please include your names.

Name You Go By

Last Name

Homeroom Teacher *

Adams

DeBell

Dean

Nichols

I like coming to school. *

Not at all

Always

I have friends at school. *

Strongly Agree

Strongly Disagree

I get along with other kids very well. *

Strongly Agree

Strongly Disagree

I am good at staying organized. *

Strongly Agree

Strongly Disagree

I am good at planning my time well. *

Strongly Agree

Strongly Disagree

I am good at studying. *

Strongly Agree

Strongly Disagree

I get worried or anxious feeling a lot. *

Strongly Agree

Strongly Disagree

What do you worry about? (No essays or full sentences required.)

I know where Mrs. Witcher's office is. *

Yes, I do.

I think so.

No, I don't.

If I had a problem at school, I would feel comfortable telling... *

Mrs. Witcher

Mr. Hedrick

Mr. Aaron

Mrs. Dudley

My teacher(s)

Another adult

A friend

No one

Required

School counselors offer small group counseling to students who have a need. If you are interested in a lunch bunch for small group counseling on one of the following topics, select it. If you are not, select the last option. Parents must give permission for small group counseling.

I am interested in the following small groups:

Managing worries (anxiety)

Support for kids from separated/divorcing/divorced parents (AKA: Banana Splits)

School Success Skills (Organization, planning, and study skills

Grief (You will need to identify who has died and when in the open blank at the end of the survey.)

Friendship group

I don't need small group counseling.

Required

Anything else that you want the counselor to know can be written here. Please do not use this for anything that is urgent. For urgent issues, please let Mrs. Witcher know today in person or in writing that you need help.

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