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* 1. Student Instructions: The school counseling department wants to ensure we develop and provide programs that meet your needs and determine how well you believe the school counseling program serves you as a student. Please be totally honest in your responses. This survey will help us learn how many students need programs and activities on certain topics. Thank you for helping us better meet your needs. PLEASE READ EACH STATEMENT AND MARK THE MOST APPROPRIATE ANSWER CHOICE FOR YOU.

Please type your name below. Your name will only be seen by members of the counseling department.

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* 2. Grade Level

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* 3. Gender

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* 4. Answer each statement and check how true it is. I need help with the following PERSONAL concerns:

  Strongly Disagree Disagree Don't Know/Not Sure Agree Strongly Agree
Making friends
Fitting in at school
Dealing with peer pressure
Improving communication
Getting involved in school activities
Dating or relationship issues
Gender Identity/Sexual Orientation
Concerns about alcohol and/or drug use
Helping myself (gaining more self-confidence, feeling better about myself, expressing my feelings and thoughts)
Handling teasing or being bullied
Getting along with other students better
Getting along better with family members
Feeling sad or depressed
Feeling suicidal
Grief over the loss of a loved one
Parental divorce or separation
Parent who is in jail
Dealing with anger
Feeling stressed
Skills for resolving conflicts

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* 5. Please choose yes or no

  Yes No
Do you frequently worry about your weight?
Have you intentionally harmed yourself?
Do you need help with dealing parental separation or divorce?

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* 6. I need help with the following SCHOOL concerns:

  Strongly Disagree Disagree Don't Know/Not Sure Agree Strongly Agree
Being more organized
Managing my time better
Improving study skills
Reducing test anxiety
Improving test-taking skills
Understanding what my test scores mean in relation to academic and career planning
Understanding the best career options for me
Planning my options after high school
Understanding my learning style to improve how I learn
Understanding graduation requirements

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* 7. Please check how much you agree with the following statements:

  Strongly Disagree Disagree Neither Agree or Disagree Agree Strongly Agree
My counselor is available to me when I need to see him/her
I feel comfortable going to see my counselor to get help with SCHOOL concerns
I feel comfortable going to see my counselor to get help with PERSONAL concerns
I like coming to school
My teachers are willing to help when I have questions

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* 8. Please choose Yes or No

  Yes No
Do you feel safe at schoool?
Do you feel safe at home?
Do you feel all of your needs are being met? (Clothing, Food, Shelter)

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* 9. Please choose yes or no for the following questions.

  Yes No
I plan to go to a 4 year college.
I plan to go to a 2 year community/technical college.
I plan to join the military after high school.
I plan to get a job after high school and not attend college.
I do not plan to graduate high school.
I am not sure of what I want to do after high school.

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* 10. Please choose yes or no

  Yes No
Are you being taken care of by someone other than your mother or father? (Not including stepparent)

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* 11. Please choose Yes or No

  Yes No
I have a parent who has been or is currently in jail
I have an parent/guardian or brother/sister who currently serves in the Army, Marines, Navy, Air Force, Coast Guard, or National Guard.
I have experienced the death of a parent or sibling

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* 12. Please list any other concerns that YOU PERSONALLY need help with

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