Weekly Student Well-being Check-in
Please complete this form to help us support your well-being. Your responses are confidential and will be used to provide assistance if needed.
Full Name
*
First Name
Last Name
Date of Check-in
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How are you feeling overall this week?
*
Very Good
Good
Okay
Not Great
Struggling
Other
Please rate the following aspects of your well-being this week:
*
Rows
Excellent
Good
Fair
Poor
Physical health
1
2
3
4
Emotional well-being
5
6
7
8
Sleep quality
9
10
11
12
Energy levels
13
14
15
16
How would you describe your current stress level?
*
No Stress
1
2
3
4
5
6
7
8
9
Extreme Stress
10
1 is No Stress, 10 is Extreme Stress
Are you experiencing any academic challenges this week?
*
No, everything is manageable
Yes, a few minor challenges
Yes, significant difficulties
Do you feel you have enough support from friends, family, or school staff?
*
Yes, definitely
Somewhat
Not really
No, I feel isolated
Would you like someone from the support team to contact you?
*
Yes, please contact me
No, I do not need support
What has been the highlight of your week?
Is there anything else you’d like to share or any concerns we should know about?
Submit Check-in
Should be Empty: