Bully Report Form

I am being bullied and this is what I have tried to do:

I did nothing
I feel scared or frightened
I feel angry

I feel alone

Told them to stop

Talked to my parent about it

Walked away

Tried to ignore it

Asked a friend for help Told a teacher or other adult

at school
My name __________________________________
The person or persons bullying me _________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___
Date of first contact __________________
Conflict resolution meeting held _____________
The problem is happening again with the same person ______
The problem is happening with another person now _____
Comments:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
___________________________________________________________

Needs Assessment Form

Name ______________________________

Grade 5

DIRECTIONS: Read each statement carefully. Rank the five (5) statements that worry you the
most. Number one (1) is the biggest worry that you have, number 2 is the second biggest, and
so forth. Write the number on the line.
___ Need information about alcohol and/or drug abuse
___ Overweight
___ Eating problems
___ Worried about death or dying
___ Often tense or uptight (stressed out)
___ Dont know how to study or stay organized
___ Afraid of failing at school
___ Not getting along with a teacher
___ Afraid to speak up in class
___ Parents are separated, divorced, or fighting
___ Parents dont understand me
___ Worried about making friends or getting along with friends
___ Have trouble with my temper, feeling angry
___ Getting into trouble
Other concerns I have (not listed above):
1.
2.
3.
4.
I would like to visit with the counselor (circle one):
as soon as possible

not right now

just to see my file and records

I would like to be in a group (circle as many as you want):

Friendship Skills
Parents Divorced/Separated
Anger ManagementStudy Skills
Other ideas for a group: ________________

YES

New Kids Group

NO

[Note to parents: this survey will be taken on-line]

Anonymous Youth Behavior Survey

Directions: please read each question carefully. Select the answer that best fits for you.
Remember, please be honest with your answers and all answers are anonymous.
School Work
1) On average, how much time do you spend doing homework each night?
a) Less than 1 hour
b) One to two hours
c) Three to four hours
d) Four or more hours
2) On average, are you given enough time in class to complete class work assigned to you?
a) Yes
b) Most of the time
c) Sometimes
d) Not usually
3) In
a)
b)
c)
d)

which class do you usually have the most homework?

English/literature
History
Math
Science

4) In the class that you have the most homework, how much classtime are you given to
complete the work?
a) Usually half or more of the class
b) Usually less than half of the class
c) Not very much class time
d) No class time, its all assigned as homework
5) The grades I typically earn in school are:
a) Mostly As and Bs
b) Mostly Bs and Cs
c) Mostly Cs and Ds
d) Mostly Ds and Fs
6) Select the situation that best describes doing schoolwork at home:
a) I can successfully do my schoolwork at home without help
b) I sometimes need help with my schoolwork at home
c) I often need help with my schoolwork at home
7) Who helps you with your schoolwork at home?
a) Parent or guardian
b) Brother or sister
c) Friends or neighbors
d) I dont have anyone to help me
e) Other
8) How often do you complete your assigned homework?
a) All the time

b)
c)
d)
e)

Most of the time

Sometimes
Rarely
Never

9) How often do you have big assignments (book report, oral presentation, region report, etc.)
or major tests from 2 or more classes due around the same time?
a) Often
b) Sometimes
c) Rarely
d) Never
Tobacco Use
1) How many times in your lifetime have you used tobacco?
a) Never
b) 1 3 times
c) 4 or more times
2) How many times in the past 30 days have you used tobacco?
a) None
b) 1 3 times
c) 4 or more times
3) Where do you usually get tobacco?
a) I do not use tobacco.
b) I get it from my parent/guardian.
c) I get it from my friends.
d) I get it from an older brother or sister.
e) I buy it myself.
f) I ask adults to purchase it for me.
g) Other.
Alcohol Use
1) How many times have you used alcohol during the last 30 days (other than for family
tradition or religious purposes)?
a) Never
b) 1 3 times
c) 4 or more times
2) How many times in your lifetime did you drink enough to feel drunk?
a) Never
b) 1 3 times
c) 4 or more times
3) How many times in your lifetime did you drink alcohol at home?
a) Never
b) 1 3 times
c) 4 or more times
4) How many times in the your lifetime did you drink alcohol before or after school?
a) Never
b) 1 3 times
c) 4 or more times

5) How many times in your lifetime did you drink alcohol during school or at a school sponsored
activity?
a) Never
b) 1 3 times
c) 4 or more times
6) Where do you most often get the alcohol you drink?
a) I dont drink
b) At home with parent consent
c) At home without parent consent
d) From friends or siblings
e) Ask an adult to purchase it
f) I buy it myself
g) Other
Drug Use
1) How many times have you used marijuana (weed, bud, pot) or hashish (hash, hash oil) in
your lifetime?
a) None
b) 1 3 times
c) 4 or more times
2) How many times have you taken amphetamines (meth, uppers, cross tops, speed, pep pills,
crank, crystal meth) in your lifetime?
a) None
b) 1 3 times
c) 4 or more times
3) How many times have you used an illegal drug or substance (other than marijuana,
amphetamines, alcohol or tobacco) in your lifetime?
a) None
b) 1 3 times
c) 4 or more times
4) Where do you most often get drugs (other than alcohol or tobacco) that you use?
a) I dont use drugs
b) At home with parent consent
c) At home without parent consent
d) From friends or siblings
e) From a dealer
f) Other
5) Based on your experience or personal knowledge, is it possible to get drugs in school or on
school grounds?
a) No
b) Dont know
c) Yes, from other students
d) Yes, from outside dealers
e) Yes, from both students and outside dealers
Safety/Climate
1) How safe do you feel when you are at school?

a)
b)
c)
d)
e)

Very safe
Pretty safe
Not very safe
Unsafe
Dont know

2) What is the biggest threat to your safety at Enumclaw Middle School?

a) There is no threat to my safety; I feel very safe at EMS
b) Violence or threats of violence
c) Vandalism of my stuff
d) Bullying or harassment towards me
e) Other
3) During your lifetime, how many times have you carried a weapon (knife, gun, club, pepper
spray) to school because you thought you might need it for self-protection?
a) Never
b) 1 3 times
c) 4 or more times
4) Choose one of the following that you see as the biggest concern for students at EMS.
a) Alcohol, tobacco, or other drugs
b) Harassment or bullying
c) Violence
d) Discrimination
e) Apathy (not caring)
5) If you are ever concerned about your safety, is there at least one adult at school you would
feel comfortable talking with?
a) Yes
b) No
6) In
a)
b)
c)
d)

general, do you feel you are treated fairly at EMS?

Yes
Sort of
Not really
No

7) In
a)
b)
c)
d)
e)

general, do you feel staff members at EMS care about student concerns?
All of the time
Most of the time
Sometimes
Not very often
Not at all

Sexual Activity
1) With how many people have you had sexual intercourse?
a) I have never had sexual intercourse.
b) 1 - 3 people
c) 4 or more people
2) With how many people have you participated in oral sex?
a) I have never participated in oral sex.
b) 1 - 3 people

c) 4 or more people
3) Do you consider oral sex to be an act of sex?
a) Yes
b) No
4) Where do you most often engage in any form of sexual activity?
a) I do not engage in sexual activity
b) At home while my parent/guardian is gone
c) At home while my parent/guardian is also at home
d) At school or during a school activity
e) Somewhere other than home, school, or a school activity
Future Plans
1- What do you plan to do after high school?
2- I dont plan to graduate from high school
2- Attend college or a university
2- Attend a technical, trade, or apprenticeship training program
2- Enter the military
2- Get a job
2- Dont know
Notes:
1) Material and/or wording for all alcohol, tobacco, or drug related questions was borrowed from
Kennewick School Districts Kennewick Schools Student Survey from the District Alcohol
and Other Drugs of Abuse Committee (http://www.ksd.org/; Kennewick School District, 524
South Auburn Street, Kennewick, WA, 99336, 509-222-5000. There are no copyrights on
Kennewicks material; however, reference for credit is recommended
2) Other questions were developed by Enumclaw Middle School (Enumclaw Middle School, 550
Semanski Street, Enumclaw, WA, 98022). There are no copyrights on Enumclaw Middle
Schools material; however, reference for credit is recommended.

Junior High School Career Exploration Day

Student Name_____________________________
Career/Business___________________________ (Your Choice)

1. Does this career require specialized training or certification? (On the Job Training,
Technical School, Associate Degree, Bachelor's Degree, Graduate School)
______________________________________________________________________
______________________________________________________________________
_______
2. What are the general skills needed for this career?
______________________________________________________________________
______________________________________________________________________
_______
3. What school subjects are important for success?
______________________________________________
______________________________________________
______________________________________________
4. What are the entry level and experienced salary ranges?
______________________________________________________________________
______________________________________________________________________
_______
5. What will be the employment opportunities for this career be in 5-10 years?
______________________________________________________________________
________________________

Return this form to your homeroom teacher

Individual Counseling Referrals

Date: ________
Teachers name: ___________________
Students name: ___________________
Reason for Referral:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
__________________________________________________________________________
Contributing Factors or Important Information needed by Counselor:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
__________________________________________________________________________

Teachers Expectation or Desired Outcome from Individual Counseling Sessions:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
__________________________________________________________________________
Has this issue been discussed with parents/guardian?

If Counselor determines that the student will need more than 3 sessions will parents/guardian
be willing to sign a permission slip?

If this is to be an on-going counseling situation what day and time would work with your class
schedule? ___________

References
American School Counselor Association (ASCA). (n.d.). Retrieved November 21, 2015, from
https://www.schoolcounselor.org/school-counselors-members/asca-resourcecenter/sample-school-counselor-forms-needs-assessments/sample-documents