Saint Paul Catholic Newman Center; Fresno, California
School Age Health Ministry Needs Assessment Survey (To Be Filled out by Parents/Gardians)
MIND, BODY AND SPIRIT
*
1.
What health-related needs would you like to see addressed at Saint Paul Catholic Newman Center?
Select all that apply
(Required.)
Academic Difficulties (Learning disabilities, Organizational skills)
Breathing or Respiratory Problems (Asthma, shortness of breath, bronchitis)
Bullying (Cyber or Physical)
Concussions
Digestive (Constipation, Diahrrea)
Emotional (Anxiety, Depression, Grief/Loss)
Pain
Physical Inactivity (Balance activity and screen time)
Nutrition (Overweight, Underweight, Body Image concerns)
Sleep Difficulties
Social Skills
Smoking / Tobacco Use
Suicide
Substance Abuse
Trauma (Abuse - Physical, emotional or financial)
Vaccinations
Other (please specify)
*
2.
Select your
TOP
Priority from Question #1
(Required.)
Academic Difficulties (Learning disabilities, Organizational skills)
Breathing or Respiratory Problems (Asthma, shortness of breath, bronchitis)
Bullying (Cyber or Physical)
Concussions
Digestive (Constipation, Diahrrea)
Emotional (Anxiety, Depression, Grief/Loss)
Pain
Physical Inactivity (Balance activity and screen time)
Nutrition (Overweight, Underweight, Body Image concerns)
Sleep Difficulties
Social Skills
Smoking / Tobacco Use
Suicide
Substance Abuse
Trauma (Abuse - Physical, emotional or financial)
Vaccinations
*
3.
Select your
2nd
Priority from Question #1
(Required.)
Academic Difficulties (Learning disabilities, Organizational skills)
Breathing or Respiratory Problems (Asthma, shortness of breath, bronchitis)
Bullying (Cyber or Physical)
Concussions
Digestive (Constipation, Diahrrea)
Emotional (Anxiety, Depression, Grief/Loss)
Pain
Physical Inactivity (Balance activity and screen time)
Nutrition (Overweight, Underweight, Body Image concerns)
Sleep Difficulties
Social Skills
Smoking / Tobacco Use
Suicide
Substance Abuse
Trauma (Abuse - Physical, emotional or financial)
Vaccinations
*
4.
Select your
3rd
Priority from Question #1
(Required.)
Academic Difficulties (Learning disabilities, Organizational skills)
Breathing or Respiratory Problems (Asthma, shortness of breath, bronchitis)
Bullying (Cyber or Physical)
Concussions
Digestive (Constipation, Diahrrea)
Emotional (Anxiety, Depression, Grief/Loss)
Pain
Physical Inactivity (Balance activity and screen time)
Nutrition (Overweight, Underweight, Body Image concerns)
Sleep Difficulties
Social Skills
Smoking / Tobacco Use
Suicide
Substance Abuse
Trauma (Abuse - Physical, emotional or financial)
Vaccinations
Other repsonse from question #1
*
5.
What Availibility of Resources / Programs would you like to see?
Select all that apply
(Required.)
Chronic /Terminal Illness
Parenting Skills (Blended families, Parenting Grandchildren)
Aoption / Foster Care
Other (please specify)
*
6.
What is your
TOP
priority from question #5
(Required.)
Chronic / Terminal Illness
Parenting Skills (Blended families, Parenting Grandshildren)
Adoption / Foster Care
Other response from Question #5
*
7.
What is your
2nd
priority from question #5
(Required.)
Chronic / Terminal Illness
Parenting Skills (Blended families, Parenting Grandshildren)
Adoption / Foster Care
Other response from Question #5
*
8.
What is your
3rd
priority from question #5
(Required.)
Chronic / Terminal Illness
Parenting Skills (Blended families, Parenting Grandshildren)
Adoption / Foster Care
Other response from Question #5
9.
Other comments pertinent to this survey