Name

Age

________Grade

INDIVIDUAL STUDENT NEEDS SURVEY

These are the things that concern me
about myself:

Feeling good about myself

Sharing my feelings
Changing my behavior
Worrying, especially about_________________________________

about friends:

Making and keeping friends in school

Making and keeping friends at home
Handling teasing, name-calling, or fighting
Working out problems with friends

about school:

Getting along with teachers

Getting my school work done
Getting my homework done
How I feel about myself as a learner

Most of the time I feel_______________________________________.

Here's something else I would like to share_________________________
_________________________________________________________
_________________________________________________________.