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Do you know who is your school counselor?
 
YES
 
NO
 
NOT SURE
 
 
 
Did you enjoy the activities provided by my counselor last year.
 
Yes
 
No
 
Not Sure
 
 
 
My Favorite Activity that I remember from last year is
   
 
 
 
These are the things that concern me…

…about myself:
 
Feeling good about myself
 
Sharing my feelings
 
Changing my behavior
 
Worrying, especially about
 
 
 
These are the things that concern me…
…about friends:
 
Making and keeping friends in school
 
Making and keeping friends at home
 
Handling teasing, name calling, or fighting
 
Working out problems with friends
 
 
 
These are the things that concern me
 
Getting along with teachers
 
Getting my school work done
 
Getting my homework done
 
How I feel about myself as a learner
 
 
 
How satisfied are you with our services?
Very Unhappy
Neutral
Happy
 
 
 
Comments/Suggestions:
   
 
Thank you for participating.