Heritage Elementary School: Needs Assessment

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The Student Services team uses the needs assessment to determine what we can do to best support students and families. If you mark any of the options below, our school social worker, Samantha Quiel, will contact you for next steps and potential referrals. Please do not add any confidential information to this form. If you have any questions, please email Ms. Quiel at squiel@wcpss.net

If you have more than one student at the same school, please fill this out for each student.

*Please note that resources are not guaranteed to be available.

Preferred method of communication *

Phone

No preference

Email *

Phone Number *

Student Name *

Parent/Guardian Name *

Please check all that apply *

My child needs clothing.

My child needs school supplies

I would like information on food

I would like housing resources

I would like information on Adult Education and/or Job Resources

I would like information on a furniture referrals

I would like mental health referrals

I would like to be considered for Thanksgiving Assistance

I would like to be considered for Christmas Holiday Assistance

I am not interested in any of the above.

Required

Does your family have a working computer at home? *

Yes

Have you used school social work services in the past? *

Yes

If you have used school social work services, how?

What are your child's interests? *

Is there something else you would like the school social worker to contact you about? *

Yes (If yes, Ms. Quiel will contact you to discuss further)

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