Crisis Care Counselor Feedback Form

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Please submit this form each time you respond to a school site crisis or disaster.

Email *

Date of Response *

YYYY

First Name *

Last Name *

Name of school attended: *

Time arrived: *

Time

Time departed: *

Time

Type of disaster/crisis response: *

Death of student

Death of teacher

School shooting

Natural disaster (fire, flood, earthquake, etc)

Other:

Number of students seen for counseling support:

Number of staff seen for counseling support:

Number of students and staff referred to school site for additional, follow-up counseling support or intervention:

The school site provided counseling space:

Yes

Other:

Clear selection

The school site provided counseling materials (arts and crafts supplies, games, fidgets, etc):

Yes

Other:

Clear selection

Suggestions for future responses at this school site, or for this type of crisis (optional):

Is there anything we should know about responding to this school site in the future? Are there any changes to the SOS response that you would suggest? What might have been more helpful to you, or to the school staff and students?

Please share any additional feedback here:

Submit

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