* 1. Grade?

* 2. I need help with the following PERSONAL concerns: (Please select all that apply)

* 3. I need help with the following SCHOOL concerns: ( Please choose all that apply)

* 4. I know who my counselor is.

* 5. I feel comfortable going to see my counselor to get help with SCHOOL concerns.

* 6. I feel comfortable going to see my counselor to get help with PERSONAL Concerns.

* 7. My counselor has met individually with me least once to help me plan my schedule for next year.

* 8. The school is involved in helping me to develop an education plan.

* 9. There is at least one staff member in the school that I believe cares deeply about me and my success.

* 10. I have a clear career plan to follow when I graduate.

* 11. I am involved in at least one school activity outside of class.

* 12. I understand why I need a good education.

* 13. I will stay in school until I graduate high school.

* 14. I will continue my education after high school.

* 15. OTHER CONCERNS: Please list any other concerns or needs that were not mentioned that YOU PERSONALLY would like the school to help you with. If you desire, you may leave your name so that the counselor may contact you

* 16. Please type your email address in the text box below

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