Student Check-In

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Student Check-In

Thank you for taking the time to check-in! Your answers will help me know how I can best help. You don't have to answer all the questions. Please be honest. There are no right or wrong answers, and I am the only one who will see your responses.

What is your name?

What is your teacher's name?

How have you been feeling in the past week?

Happy or peaceful

Sad or unhappy

Lonely

Tired

Afraid

Angry

I feel like I need to talk to someone about how I feel

Confused

I feel normal

Anxious

Who do you talk to in your family if you have a problem?

Right now I am having trouble learning because...

I do not have a computer, laptop, tablet or phone

I have a sick family member

I do not have a quiet place in my house to learn

I am worried about something

I do not like online learning

I have trouble sitting still at the computer

I am NOT having trouble learning

Other:

Is there anything going on at home or in your classroom that you would like the counselor to know about?

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