Student Wellness Care Plan
Help us design a tailored wellness plan to support your needs and well-being at school.
Student Full Name
*
First Name
Last Name
Grade/Year Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Information
*
Primary Wellness Concerns
*
Physical health (e.g., nutrition, sleep, chronic illness)
Emotional well-being (e.g., anxiety, mood, stress)
Social relationships (e.g., peer issues, bullying)
Behavioral concerns
Academic challenges
Other
Current Wellness Supports/Services (in place or received)
Wellness Goals (What do you hope to achieve?)
*
Planned Interventions or Strategies
*
Responsible Person(s) for Plan Implementation
*
Review/Follow-up Date
-
Month
-
Day
Year
Date
Additional Notes or Comments
Signature of Parent/Guardian or Student (if 18+)
*
Submit Care Plan
Submit Care Plan
Should be Empty: