Name of School

LOCAL COUNSELING NEEDS ELEMENTARY TEACHER SURVEY

Based on your observations, check the appropriate box for items that are concerns interfering
with the learning process for your students.
CONCERNS
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Fights
Difficulty getting along with friends or others
Anxious around others
Afraid to talk with the teacher
Difficulty making friends
Not knowing how to ask for help with problems at school and/or home
Participating in class
Low self-regard
Assertiveness
Difficulty communicating feelings
Teasing, bullying
Anger control
Having an adult to turn to for help
Feeling safe at school
Dealing with change/new situations
Receiving one or more failing grades on a report card
A divorce, separation or death in the family
Loss of a loved one
Loss of a close friend or relationship
Stress
Hurting/cutting oneself
Thinking/talking about suicide
Feeling sad or depressed most of the time
Rumors and gossip
Eating disorders
Not accepting peoples differences
Afraid to come to school
Fear of making mistakes
Skipping school
Test anxiety
Not getting along with teachers
Family addictions
Physical/sexual abuse
Neglect
Inattention/hyperactivity
Homelessness
Poverty
Domestic violence

CHECK

Small Groups Needs Assessment

Name: __________________________________
Grade Level:

The counseling department is working on determining the need for small group guidance. Below
are some suggested topics that could be covered in groups. Please indicate which needs you
think could benefit your students by circling the appropriate number.
Extreme
Need

Need

Self-Esteem

Friendship

Divorce

Somewhat
Needed

Very Little

Little,
if any

Study Skills

Bullying

Victims of Bullying

Anger Mgt

Manners

Grief

Social Skills

Please list below any other topics for which you think a need may exist.
_________________________________
_________________________________
Thank you for your participation. Please return to your grade level counselor as soon as
possible.
The Counseling Department

Bullying Survey
Please tell us if there is anyone bullying you and who the people are doing the bullying.
Your information is confidential and you will not be identified.
Name (optional) __________________________________ Date ________________
Grade ______________

Boy ___ Girl ___

1. Do you feel safe at school?

2. Have you ever been bullied at school?
3. Did you tell anyone about the bullying?
If not please explain why?
4. Is anyone mean to you in class or at school?
5. Is anyone hitting or teasing you in the restrooms?
6. Are you bullied in the halls?
7. Are you being bullied on the playground?
8. Are you being bullied at lunch?
9. The last time you were bullied did you get help?
If not, why didnt you seek help?
10. Do you know anyone that is being bullied and not getting help at this time?

11. What do you think will help stop bullying in our school?

Thank you for taking a positive stand in helping stop bullying in our school.

Student Behavior Chart

Tracking form for _________________________ circle the way I think my behavior is for the
morning and afternoon for each day. If my teacher disagrees, their will is a line through my
choice and another choice circled. I want to change my behavior and this will help me do it. I
need to show this to my counselor at our weekly sessions, so we can continue to work on goal
setting together.
Date:

Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon
Morning
Afternoon

How is my behavior

Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great
Great

Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average
Average

Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor
Poor

Comments:

SCHOOL COUNSELING REFERRAL FORM

DATE _______________ AGE ______________________ GRADE ______
STUDENT'S NAME ______________________________ BIRTH DATE M___/ D ___/ Y_____
ADDRESS __________________________________________HOMEPHONE _______________
MOTHER'S NAME_______________________________ WORK/CELL PH._________________
FATHER'S NAME _______________________________ WORK/CELL PH. _________________
STUDENT LIVES WITH _________________________________
TEACHER ________________________________
Is the student receiving Special Services? [ ] No [ ] Yes
If Yes, please list:
Reason(s) for referral:
[ ] Motivation

[ ] Bullying

[ ] Swearing

[ ] Stressed Concerns

[ ] Divorce

[ ] Fighting

[ ] Worries

[ ] Peer Relationships

[ ] Friendship

[ ] Absences

[ ] Anger

[ ] Destruction of Property

[ ] Dishonest

[ ] Withdrawn

[ ] Trust

[ ] Personal Hygiene

[ ] Inattentive

[ ] Death

[ ] Fears

[ ] Perfectionist

[ ] Hyperactive

[ ] Stealing

[ ] Lying

[ ] Social Skills

[ ] Depression

[ ] Drugs

[ ] Other _________________________________________________________________________
Concerns______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
REFERRED BY_______________________________________
PERMISSION TO PROVIDE SCHOOL-COUNSELING FORM

Date sent _________________

Date returned _____________

Principal Notified of Counseling Services: Date ____________________

Counselor's Signature _________________________________________