MNPS Middle School Virtual Needs Assessment

Since we are returning to school in a virtual setting due to Covid-19, we don't have the ability to interact with you in a way that we are both familiar. However, we still want you to know that we are here for you and to provide any support that
you may need. We would like for you to answer the following questions below so that we can help support you and/or your family if you have any needs or concerns. This assessment is completely voluntary. It is your choice whether you
want to answer these questions. If you choose to complete this survey, your answers are confidential unless you express the need for support. If support is needed, your answers will only be shared with the adults that will be supporting you
and your family. After all responses are received, someone from the school will be reaching out to you, if you indicate a need for support.

**If you are currently in crisis and need immediate assistance, please contact 911 or visit the nearest emergency room. If you need to talk to a crisis counselor, please call 855-CRISIS-1 or text HOME to 741741 for free 24/7 support.

* Required

* This form will record your name, please fill your name.

1. Please select your grade level:

5th

6th

7th

8th

2. Please check one:

Male

Female

Prefer not to answer

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 3. Please look at the following list of concerns. I need help with the following PERSONAL concerns
(Select all that apply): *

Helping myself (gaining self-confidence, feeling better about myself)

Dealing with my anger

Worrying/Feeling stressed

Feeling extremely sad

Grief over the loss of a loved one

Parental divorce or separation

Gender and/or sexual orientation issues

Dealing with a parent that is in jail or prison

Relationships at home

I do not need help at this time

Other

4. I need help with the following SCHOOL concerns (Please select all that apply): *

Organization/Time Management in a virtual learning setting

Gaining access to a computer

Gaining access to the internet

Having a quiet space at home to complete my school work

Obtaining school supplies

Getting picked on and/or bullied by others

Controlling my anger

Making better grades

I do not need help at this time

Other

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 5. My family and I need help with the following (Please select all that apply): *

Food

Clothing

Housing

Medical

Counseling

School Supplies

We do not need help at this time

Other

6. The hobbies that I enjoy doing outside of school (ex. sports, reading, dancing, etc.) *

7. I have at least one caring adult outside of school that I can talk to if I have a problem. *

Yes

No

8. Please provide your first and last name: *

9. Please provide your date of birth. *


Format: M/d/yyyy

10. If you know your student ID number (190#), please enter it here:

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 11. Would you like to schedule a meeting with a school staff member in the future? *

Yes

No

Maybe

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11/12/2020