3/19/2018 Shepard Middle School Student Needs Assessment 2017-2018

Shepard Middle School Student Needs

Assessment 2017-2018
Please read carefully and answer all of the questions. All information shared on this form will be
CONFIDENTIAL and only your school counselors will view. We look forward to a great year and
remember that we are always here to help you! Thank you!

Mrs. Teal, Mr. Perkins, and Ms. Brashears

* Required

First Name *

Your answer

Last Name *

Your answer

Grade *

6th

7th

8th

Homeroom Teacher Name *

Your answer

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Race/Ethnicity *

African American

Hispanic/Latino

Asian American

White/Caucasian

Native American

More than one race

Other:

Do you have a parent or caregiver that is incarcerated (in prison)?

Yes

No

Academics & School

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I need help with the following SCHOOL concerns:

Please darken the circle by clicking Yes or No

Yes No

Managing my time and being

organized

Test anxiety and test-taking skills

Getting better grades

Setting goals

Using study skills

Selecting and getting into college

Being respectful to my teachers

Working and getting along with

classmates

Managing my stress

How often are you worried about dropping out of school or missing
class?

Never

Less than once a week

Once a week

2-4 days a week

Every day

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How often are you worried about managing your anger during
class?

Never

Less than once a week

Once a week

2-4 days a week

Every day

Personal & Social Life

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I need help with the following PERSONAL/SOCIAL concerns:

Please darken the circle by clicking Yes or No

Yes No

Making friends / Fitting in at

school

Dealing with peer pressure

Handling teasing, bullying, or

harassment

Getting along with other

students/ con ict resolution

Feeling stressed

Pregnancy

Coping with grief/loss/death

Drugs or alcohol

Handling rumors, gossip, and

drama

Hurting or cutting myself

Learning to live in a new culture

Feeling sad or depressed often

Nutrition / healthy eating &

healthy lifestyle

Dealing with family changes

(divorce, separation, etc.)

Interacting with people who are

different than me

Fear of making mistakes/

wanting to be perfect

Managing anger/avoiding ghts

Being afraid to go home after

school
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Gaining leadership and team

skills

Help with transition into middle

school or a new school

How often do you experience PHYSICAL harassment when you are

at school?

Never

Less than once a week

Once a week

2-4 days a week

Every day

How often do you experience VERBAL or EMOTIONAL harassment

when you are at school?

Never

Less than once a week

Once a week

2-4 days a week

Every day

How often do you think about suicide (taking your own life)?
1 2 3 4

Never All the time

Small Group Topics

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I would like to participate in a SMALL GROUP about these issues:

Please check all that apply

Personal relationships/friendships (including drama)

Family issues/changes

Self-esteem

Anxiety/worrying/stress

Con ict resolution/anger management

Goal setting

Bullying

Transition to middle school

Latino/a Identity Group

Study skills, organization, test-taking skills

Staying motivated to do well in school

Dealing with grief/loss/death

Leadership/Teamwork

Other:

Career Development

Are you considering going to college?

1 2 3 4

Not at all De nitely!

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Do you have ideas about what you want to do as a career?

1 2 3 4

Not at all De nitely!

Do you know about tasks, duties, or other information about the

career or job that interests you?
1 2 3 4

Not at all De nitely!

Do you know about the education needed for the career you want?
1 2 3 4

Not at all De nitely!

Final Thoughts

You're almost done! Be sure to click submit at the end!

Are there other topics that are not listed above that you would like
your counselors to know about?
Your answer

Would you like to talk with your counselor individually to discuss

any of your concerns ?

Yes

No

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