Reilly Elementary Needs Assessment

Please answer the following questions to the best of your ability. We would really like to
hear your opinion. There are no wrong answers.Thank you!
What grade are you in?
4th Grade
6th Grade
8th Grade
What is your gender?
Male
Female
I would like to not answer this question.
Please check off which options best describe you.
Latino/Hispanic
White/ Caucasian
African/ African American/ Black
Asian/ Asian American/ Pacific Islander
American Indian/ Native Alaskan/ Hawaiian
Other (please type response in box) ____________________
What is the main language spoken in your home?
English
Spanish
Polish
Other (please type response in box) ____________________
Please select who lives in your household. (select all that apply)
Mother
Father
Step-Mother
Step-Father
Siblings (Full, Half, Step)
Grandmother
Grandfather
Uncle
Aunt
Cousins
Other (please type response in box) ____________________

What are your plans for after high school?

Work
Military
College/Trade School
I'm not sure.
Other (please type response in box) ____________________
What grades are you usually getting in class?
A
B
C
D
F
I have family members that care about my school performance.
True
False
I know what to do when I need help with school.
True
False
What services would you use to make your grades better? Please rank the options 1
through 5, with 1 being the service you would most likely use and 5 being the service
you would least likely use.
______ Before/After school access to teachers
______ Individual support time during class
______ Help from peers
______ Additional access to school counselors
______ Intervention time
What are some obstacles that might prevent you from continuing your education after
high school? Please check all that apply.
Cost of college
Grades
Family responsibilities
Motivation
None
Other ____________________
There is at least one staff member in the school who I believe truly cares about me and
my academic success.
True
False

I need help learning how to talk to an adult (teacher, counselor, administrator) at school.
True
False
I know who my school counselor is.
True
False
I like school.
True
False
I am stressed by
School/Academics
Friends/Social
Personal/Things outside of school
None of the above
Other ____________________
I have family members that care about my well-being.
True
False
I have at least one good friend at school.
True
False

I need help with the following:

Disagree
Voicing my concerns
and speaking up for
myself with others
Knowing how to
manage stress in a
positive way without
hurting myself and
others
Responding to myself
or other students
being bullied,
mistreated, or feeling
alone in school.
Learning new
strategies that would
help me resolve
conflict

Neither Agree nor

Disagree

Agree

Bullying is a problem at my school

True
False
Please choose all that apply. When bullying happens it is usually...
in the hallways
in the cafeteria
during recess
in classrooms
online
after school
other ____________________

Please select the answers that best fit you for the following statements:
Disagree
Neither Agree nor
Disagree
I feel like I have a

number of good
qualities.
I feel that I am a

person of worth.
I accept myself as I

am and am happy
with myself.
I feel like I am a

nervous or anxious
person.

Agree

When I compare myself to other people:

I usually feel good about myself
I usually feel OK about myself
I usually feel bad about myself
Are there any more counseling resources that you would like your school to offer? If yes,
please describe them below:
Please use the space below to offer suggestions, ask questions, or express your
concerns to your school counselor.