Needs Assessment

2012 - 2013 Greetings Northside Students:

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Northside College Preparatory High School

The Counseling and Social Work Departments ask for your help in gathering data. In an effort to serve you better, we are assessing students needs regarding personal/social issues here at Northside and/or at home. We ask that you provide honest and thoughtful answers. Your responses will be anonymous. After this data is analyzed, we hope to offer more comprehensive services based on your needs. Thank you!

GENERAL INFORMATION
Gender: Male Female Other Race: Caucasian African-American Asian or Pacific Islander Hispanic or Latino Native American Other

How long does it take you to get to school in the morning? Less than 30 minutes Between 30 minutes and 1 hour Between 1 hour and 1.5 hours 2 or more hours Do you receive free or reduced lunch? Yes No Is English the predominant language spoken within your home? Yes No

Generally, I receive: Mostly As As and Bs Bs and Cs Cs and Ds Ds or below Grade Level: 9 10 11 12

Consistently

Rarely

1. Anger / Difficulty with angry feelings 2. Being teased or bullied 3. Conflict in my family 4. Conflict with friends 5. Death of a loved one or friend 6. Divorce / Separation / Absent parent 7. Deployment 8. Drug / Alcohol abuse with myself, friends, or family 9. Feelings of sadness 10. Health of myself or a loved one 11. Peer pressure 12. Poor study skills 13. Problems with eating or sleeping 14. Lack of self-confidence 15. Sexual harassment at school 16. Stress / Anxiety 17. Thoughts of hurting myself / Suicide 18. Difficulty planning and setting goals 19. Not feeling welcomed / Difficulty adjusting to Northside 20. Feeling nervous about my safety 21. Relationship concerns with a significant other 22. Identity Issues 23. Other 1: 24. Other 2:

Never

Often

The following are currently affecting my ability to learn (this year at Northside). Please check one box for each question.

Sometimes

Issue #: [Date]

Needs Assessment

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Dolor Sit Amet

2012 - 2013

Northside College Preparatory High School

I feel comfortable approaching the school social worker for help: Yes No I do not know who the social worker is I feel comfortable approaching my school counselor for help: Yes No I do not know who my school counselor is I feel comfortable approaching the school nurse for help: Yes No I do not know who the school nurse is I feel comfortable going to the Wellness Center for help: Yes No I do not know where / what the Wellness Center is Please provide us with comments or suggestions that you feel will enable us to serve you better: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________

If you need to talk with your counselor immediately, please visit the Counseling Department or provide or your name and advisory below.

(Optional) Student Name:

__________________________

Student Advisory:

__________________________

THANK YOU FOR YOUR PARTICIPATION.