BSMS Needs Assessment 6th 2019

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First Name *

Last Name *

Homeroom Teacher *

I feel good about my life *

yes

sometimes

I am able to handle stressful situations *

yes

sometimes

Most of the time I am happy at school *

yes

sometimes

I have friends at school *

yes

sometimes

I feel sad or depressed a lot of the time *

yes

sometimes

I am happy with my school work and grades *

yes

sometimes

I get along with my family *

yes

sometimes

I have a hard time controlling my anger *

yes

sometimes

I plan on graduating from high school *

yes

sometimes

Last year the school I attended was *

Butner-Stem Elementary School

Creedmoor

Mount Energy

Tar River

Hawley

Wilton

Sonstiges:

One unique or special thing about me is *

I received food assistance or back pack buddies in Elementary School.

Yes

Auswahl löschen

I have a relative who was incarcerated (in jail or prison).

Yes

Auswahl löschen

If you have a relative who was incarcerated what is their relationship to you? (Mom, dad, step dad, step mom, uncle, brother, etc)

If you have a relative who is incarcerated is there anything you want to tell me?

The best part of my summer was *

The worst part of my summer was *

Right now, my plans after I graduate high school are *

Please select any group or activity that you might be interested in *

stress management

anger management

grief/loss

decision making/assertiveness

organization/study skills

book club

I am not interested in a group

Pflichtfrage

Have there been any changes in your life over the last few months? *

Is there anything you need for me to know? *

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