Mental Health Survey--Parent
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Parent Name *
Child's Name *
Child's Grade *
How excited is your child about the new school year? *
Very anxious and/or worried
Very Excited
Are any of these things making your child anxious about the school year? (check all that apply) *
Required
On average, how much daily screen time does your child have outside of the school day? *
I feel like my child has enough energy for the school day? *
On average, my child gets _____hours of sleep each night? *
Over the past year, how often has your child felt lonely? *
Over the past year, my child has been so angry they have lashed out with physical aggression. *
Please rank from 1-5 (1-most often, 5 least often) the emotions your child has felt the majority of the over the past year. *
1
2
3
4
5
Angry
Happy
Excited
Sad
Calm
I know where I can find help if my child has a struggle. *
If you would like a school staff member to reach out to you, please put your name and contact information below.  
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