Estimated time: 2 minutes
Purpose: To help identify and support students who may be feeling stressed, disconnected, or in need of extra help — before challenges become bigger problems.
Privacy & Consent Statement (student-friendly):
Your answers are private and will only be shared with your school counselor and teachers who support you. They will use this information to check in and offer help if needed. You can skip any question you don’t want to answer. This survey is not a test — there are no right or wrong answers.
Section 1 – How You’re Feeling This Week
(Scale: 1 = Strongly Disagree, 5 = Strongly Agree)
- I felt calm and able to manage my emotions this week.
- I felt connected to friends, classmates, or teachers.
- I was able to focus and get my schoolwork done.
- I felt supported by at least one adult at school.
- I had enough energy to get through the school day.
Section 2 – Stress & Challenges
(Scale: 1 = Not at all, 5 = Very much)
- I felt stressed or worried this week.
- I had trouble sleeping or relaxing.
- I felt left out or isolated.
Section 3 – Open Reflection
- Is there anything you’d like your counselor or teachers to know about how you’re feeling this week? (Optional)
Section 4 – Quick Support Check
- Would you like someone from school to check in with you soon?
- ☐ Yes
- ☐ No
- ☐ Not sure
Early Signal Project 