Student Self-Care Survey (Elementary)

Adapted from the The Project for Mental Health and Optimal Development at University of Pennsylvania Graduate School of Education

The survey closes on Friday, February 26, 2021.

Parents, please review this survey with your child and complete the survey with your child. Please contact your child's Principal with any questions.

DIRECTIONS: Complete the following chart on different activities you do or don’t do. Then, think about what activities you’d like to try or to do more.

The following survey assesses your engagement in self-care and guides students to commit to ways to recharge.

Self-care is exactly what it sounds like - taking care of yourself! Self-care can be eating your favorite food (including special treats!), getting enough sleep at night, playing a game with a friend, or anything else you like to do that is good for your body.

Sometimes it can be hard to take care of yourself because of problems with friends, with family, or at school. This worksheet is to help you learn what self-care you already do, and to learn what self-care you might need to start doing to feel your best!
1.What is your first name? (the student)(Required.)
2.What is your last name? (the student)(Required.)
3.What school do you go to?(Required.)
4.What is your teacher's name?(Required.)
5.Choose one or two activities you want to try to do more to help take care of yourself.(Required.)
6.BODY SELF-CARE                    How often do you do this activity?(Required.)
Always
A lot
Sometimes
Never
I would like to try that.
Eat healthy food
Get enough sleep
Play outside/take walks
Take breaks
Rest when you feel sick
Go to the doctor
Take brain breaks
Take deep breaths when angry/upset
Take showers/baths regularly
Brush my teeth every day
7.FEELINGS SELF-CARE                    How often do you do this activity?(Required.)
Always
A lot
Sometimes
Never
I would like to try that.
Be kind to myself when I get something wrong
Draw pictures
Read
Find new things you like to do
Learn a new skill
Spend time with people who make you happy
Ask for help when needed
Talk to an adult I know and like about how I feel
8.SCHOOL SELF-CARE                    How often do you do this activity?(Required.)
Always
A lot
Sometimes
Never
I would like to try that.
Say no to my friends when they do something I don’t like
Ask for brain breaks
Play with my friends
Get my work done
Ask for help when needed
Eat during lunch (at home during virtual learning)
Focus on my work during class
9.FRIENDSHIP SELF-CARE                    How often do you do this activity?(Required.)
Always
A lot
Sometimes
Never
I would like to try that.
Spend time with people (and pets) who make me happy
Make play dates with friends
FaceTime with friends and family
Say no when someone does something to me I don' like
Make new friends
10.Which activities make you feel the best? Why?(Required.)
Current Progress,
0 of 10 answered