Holy Angels Catholic School

School Counseling Department

Student Needs Assessment
Please follow the directions for each section below. All answers
on this form will remain confidential and will only be seen by
the Holy Angels counseling staff.
Read each statement and select the box that best
represents YOUR answer. Do not leave any statements
unanswered.
1.

What is your gender?

Male
Female
I choose not to answer this question

2. Please check which race/ethnicity best describes you.

African/African American/Black
American Indian/Native Alaskan/Hawaiian
Asian/Asian American
Latino/Hispanic
White/Caucasian
Other (please specify) __________________________
3. Who lives in your household? (Please check all that apply)
Mother
Father
Step-Mother
Step-Father
Siblings (full, half, step)
Grandmother
Grandfather
Aunt
Uncle
Cousin
Friend
Other: ________________________

4. I feel safe playing outside in my neighborhood.

Yes
No

5. I feel safe at Holy Angels.

Yes
No
6. I feel fighting is a good way to solve problems when I feel
upset.
Yes
No
7. I can talk to the following person/people when I have a
problem or feel upset: (Check all that apply)
My School Counselor
A Teacher
A staff member at Holy Angels
A Family Member
A Friend
Other (please specify):
_____________________________________
8. I have at least one good friend at Holy Angels.
Yes
No
9. I feel I like I can ask for help from my teacher.
Yes
No
10. I know what peer pressure means.
Yes
No
11. I do not give into peer pressure.
Yes
No
12. I use social media nearly everyday.
Yes
No

13. I have been bullied at Holy Angels.

Yes
No
14. I like to be in my home classroom.
Yes
No
15. I feel like I fit in at Holy Angels.
Yes
No
16. I think about what I would like to be when I grow up.
Yes
No
If yes, what would you like to be?
______________________________________________________
17. I recognize when someone is being a bully.
Yes
No
18. I sit with at least one person I like at lunch.
Yes
No
19. I can complete homework at home.
Yes
No
20. My family is supportive of my school work.
Yes
No
21. I want to do well at school.
Yes
No
22. I like to to learn.
Yes
No

23. I can focus in my classroom.

Yes
No
24. Someone in my house reads to me at night.
Yes
No