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Check-In
I would like to hear how you are all doing. I am happy to reach out to any of you students or families that need support. You can complete this form every day or just one time. This form is confidential and will only be seen by me.
~ Mrs. Steffy~
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* Indicates required question
Email
*
Your email
Student Name
*
Your answer
How are you feeling today?
*
1-Really Sad
2-Could be better
3-Okay (not happy or sad)
4-Pretty Good
5-Great
Other:
How was your breakfast and lunch?
Your answer
How is everything at home?
*
Terrible
1
2
3
4
5
Fantastic
Do you have everything you need?
*
Yes
No
What are some coping strategies you can use if you have BIG feelings (sad, mad, anxious, scared)?
Your answer
What are some activities you like to do while you are at home?
Your answer
How are you doing on your AMI work?
*
Your answer
Would you like a check-in call?
*
Yes
No
What is the best way to contact you?
*
Email
Phone
Text
Please include your contact information
*
Your answer
Is there anything else you would like Mrs. Steffy to know?
Your answer
Send me a copy of my responses.
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