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Wellness Check-in
Hi! It's Mr. Byrne, Mrs. Thomas, and Mrs. Wiegert here! Please let us know how you are doing and if there's anything you need. Take care, friends!
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Your Name (First and Last):
*
Your answer
Your Grade:
3rd
4th
5th
6th
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Your Homeroom Teacher:
*
Your answer
Zones of Regulation
Which feeling zone are you in?
Blue
Green
Yellow
Red
How are things overall?
*
Your answer
How do you feel about your school work?
Your answer
How are your friendships? (1 - very poor..... 5 - very well)
1
2
3
4
5
Clear selection
Thoughts? Anything you would like your school counselors to know?
Your answer
Would you like a one-on-one check-in from your school counselor or Mrs. Wiegert?
*
Yes
No
Other:
If available, who would you like to check-in with you?
Mr. Byrne
Mrs. Thomas
Mrs. Wiegert
Whoever is available :)
Thank you for checking in! We are thinking of you!
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