Student’s Name______Birthdate______Age______Gender q F q M School ______Grade______Teacher(s) ______

Parent/Guardian ______

Address ______Phone (Home) ______(Work/Other) ______

Form completed by (if different from student): ______

I am good at: (Check all that apply)

q Having a positive attitude / q Finishing what I start / q Handling conflict well
q Being a hard worker / q Being organized / q Being athletic
q Being trustworthy / q Having a good sense of humor / q Taking pride in my appearance
q Working well in groups / q Cooperating with others / q Drawing/painting/art
q Working well by myself / q Being responsible / q Singing/playing an instrument
q Being respectful / q Being creative / q Other:______
q Staying motivated / q Being a good leader / q Other:______

I have a hard time: (Check all that apply)

q Getting good grades / q Reading / q Getting along with my classmates
q Finishing my work / q With writing assignments / q Getting along with teachers
q Following directions / q Doing math / q Working well by myself
q Remembering things / q Studying for tests / q Asking for help
q Being organized / q Being responsible / q Being on time to class
q Keeping motivated / q Handling conflict / q Other:______
q Staying focused/on task / q Being respectful / q Other:______

I would like help so I can stop: (Check all that apply)

q Physically hurting people / q Saying mean things / q Giving up easily
q Being bullied / q Being shy / q Being late/skipping school
q Bullying others / q Getting mad easily / q Breaking school rules
q Destroying property / q Annoying people / q Feeling sad
q Being so distracted / q Stealing/cheating/lying / q Feeling worried/nervous
q Arguing / q Being disrespectful / q Other:______
q Being disorganized / q Getting in trouble / q Other:______

What has been done so far to help you? (Put a check next to things that helped.)

q 1) ______
q 2) ______
q 3) ______
q 4) ______