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1. What grades are you currently earning? (Check all that apply)
______ A’s _______B’s ________C’s ________D’s _________F’s
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
f. The biggest obstacles to me doing well in high school are (Check all that apply):
2. Do you want to attend college after high school? _________ Yes _________ No
a. If yes, which college, university, or trade school would you like to attend?
1. ___________________ 2. ______________________3. _______________________
___ None ___ Hanging out with friends ___ Work ___ Homework ___ Team Sports
___ Recreational Programs ___ Church Activity ___ Caring for my sibling
___ Volunteering
4. How do you usually feel daily? (1 =Good, 3=Neutral, 5 =Bad)
1 2 3 4 5
a. Would you say that you have friends?
_________ Yes ________No How many? _____________
a. I live with:
______Single Mother
______Single Father
______Two Biological Parents
______ Parent/Stepparent
______Other
b. My ethnicity is:
______American Indian/Alaskan Native
______ Asian/Pacific Islander
______ Hispanic/Chicano/Latino
______Black [Not Hispanic Origin]
______White [Not Hispanic Origin]
______ Other/ Biracial
Thank you for your time and for providing an honest response to your need’s assessment.
Sincerely,
Miss Stewart
School Counselor