* 1. How good are you at understanding the feelings of others?

* 2. How good are you at controlling your own feelings and behaviors?

* 3. How good are you at getting along with peers?

* 4. Have you struggled with your behaviors this school year?

* 5. How many times have you been to the office for your behavior this year?

* 6. Is this an increase in office referrals from previous years?

* 7. If you answered yes to questions 6, is the change in your behavior due to:

* 8. On a scale of 1-5 with 1 being poor and 5 being excellent answer the following questions.

  1 No - never 2 Sometimes 3 usually 4 Most of the time 5 Always
Do you feel cared for at home?
Do you feel cared for at school?
Do you feel you can share your feelings at home?
Do you feel you can share your feelings at school?
Do you feel you express your behavior appropriately at school?
Do you feel you express your behavior appropriately outside of school?

* 9. Would you be interested in any of the following:

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