Student Needs Assessment
Please rate each item pertaining to the student you wish to refer.
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Email *
Your Name (First & Last) *
Student Name (First & Last) *
What is your relationship to the student? *
Student's Grade *
I believe this student needs help with or more information about relationships and relationship concerns. *
I believe this student needs help with or more information about making friends and social skills. *
I believe this student needs help with or more information about communication and boundaries. *
I believe this student needs help with or more information about bullying issues. *
I believe this student needs help with or more information about peer pressure. *
I believe this student needs help with or more information about making decisions. *
I believe this student needs help with or more information about problem solving. *
I believe this student needs help with or more information about mental health (anxiety, depression, anger, feelings, ...). *
I believe this student needs help with or more information about coping skills. *
I believe this student needs help with or more information about grief and sadness. *
I believe this student needs help with or more information about drug and alcohol use concerns. *
I believe this student needs help with or more information about pregnancy and teen parenting. *
I believe this student needs help with or more information about self-harm and suicide. *
I believe this student needs help with or more information about academic skills (ie. study skills, organization, ...). *
I believe this student needs help with or more information about graduation and post-graduation plans. *
Are there any other topics or help you think would be beneficial for this student? *
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