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School Needs Assessment

Name (Optional): _________________ Teacher: _____________________ Grade: ________
Please complete this needs assessment, so that I can determine what topics for intervention,
lessons, and programs will be beneficial. All responses are confidential, unless you would like to
provide your name. The needs assessment is to be completed in your 45-minute class period,
where you obtained your assessment. Please answer the following questions:

1. What grades are you currently earning? (Check all that apply)
______ A’s _______B’s ________C’s ________D’s _________F’s

a. Do you enjoy your time at school? (1 =Always, 3=Sometimes, 5 = Never)

1 2 3 4 5

b. My teachers value me? (1 = Always, 3=Sometimes, 5 =Never)

1 2 3 4 5

c. I put in my best effort at school? (1 =Always, 3=Sometimes, 5 =Never)

1 2 3 4 5

d. Do the subject Science, Math, or computers interest you?
______ Yes _______ No

e. Have you ever repeated any grades?
______ Yes _______ No (If yes), which one(s)? _________________

f. The biggest obstacles to me doing well in high school are (Check all that apply):

___ My parents don’t help me
___ My friends don’t think school is important
___ Too many problems at home
___ My teachers don’t care about me
___ My teachers can’t teach me
___ I need to work to make money
___ Court problems
___ I don’t know English well enough
___ I don’t read well
___ My classes are too hard
___ School is too boring
___ I am pregnant
___ I have a child
___ My childcare is not good or consistent
___ My boyfriend/girlfriend or husband/wife doesn’t support my being in high school
___ I don’t need high school for my future goal(s)

g. In my school, I have seen:

___ Students being leaders ___ Students fighting
___ Parent helping out ___ College students at the high school
___ Students being given recognition for an achievement ___ Gang representation
___ Racism or discrimination ___ Girls being treated unfairly
___ Boys being sexist towards girls ___ Boyfriends hitting their girlfriends
___ Bullying or students being treated unkindly

2. Do you want to attend college after high school? _________ Yes _________ No

a. If yes, which college, university, or trade school would you like to attend?
1. ___________________ 2. ______________________3. _______________________

2. What 3 major’s interest you in college?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. Are you aware of the classes that should be taken to prepare for this career?
________ Yes __________No
3. Are you involved in extra-curricular activities?
_______Yes _______No (If yes) which ones? _______________________________________
a. What are your hobbies/ talents?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

b. After my regular classes at school end, I am involved in the following activities:

___ None ___ Hanging out with friends ___ Work ___ Homework ___ Team Sports
___ Recreational Programs ___ Church Activity ___ Caring for my sibling
___ Volunteering
4. How do you usually feel daily? (1 =Good, 3=Neutral, 5 =Bad)
1 2 3 4 5
a. Would you say that you have friends?
_________ Yes ________No How many? _____________

b. My friend value me:
___ Yes ___ No ___Sometimes

c. When I have a problem, I have someone to talk to:
___ Yes ___ No ___Sometimes

d. I have experienced the following (Check all that apply):
___Depression
___Suicidal thoughts
___Attempted suicide
___Being beaten up at home
___Being beaten up outside of home
___Racism or discrimination
___Being arrested
___Being raped or sexually assaulted
___Being robbed
___Being threatened with violence
___Passing out from drinking or drugs
___Being hit by a girlfriend or boyfriend
___Being put down by my parents or family
___Being put down by my teachers or school staff
___Being put down by other students
___Being bullied by other students
___Being put down by my friends
___Over eating
___Make myself vomit to lose weight

e. I feel safe at school:
___ Yes ___ No ___Sometimes

f. I feel safe at home:
___ Yes ___ No ___Sometimes
5. My biological gender is:
_____Male
_____Female

a. I live with:
______Single Mother
______Single Father
______Two Biological Parents
______ Parent/Stepparent
______Other

b. My ethnicity is:
______American Indian/Alaskan Native
______ Asian/Pacific Islander
______ Hispanic/Chicano/Latino
______Black [Not Hispanic Origin]
______White [Not Hispanic Origin]
______ Other/ Biracial

Thank you for your time and for providing an honest response to your need’s assessment.
Sincerely,
Miss Stewart
School Counselor