Needs Assessment Survey Template
Description: Dear students, this is a CONFIDENTIAL survey that is only seen by our counseling department. We want to give you a chance to tell us what sort of issues and counseling services are most important to YOU. We take your answers seriously. Your privacy is important to us.
Demographic
Q1: Email [short answer]
Q2: First Name [short answer]
Q3: Last Name [short answer]
Q4: Teacher Name [short answer]
Q5: What is the best number to reach you at? [short answer]
Q6: Grade [dropdown]
Q7: Counselor Name [select one]
Career/ Post-Secondary Options
Q8: What are your current plans for after High School?
Attend a 2-year college
Attend a 4-year college or university
Get vocational training (trade school)
Apply for an apprenticeship program (like electrician, welding, etc) AmeriCorps (NCCC or FEMA)
Military
Work full-time
I have no idea and need help- someone will contact me
Other:
Q9: I'm interested in getting more information about the military [select one]
Yes
No
Q10: We have many colleges that visit our campus or do virtual meetings. Which colleges would you be interested in learning more about? (Mark as many as you'd like.)
Eastern Oregon University (LaGrande)
Western Oregon University (Monmouth)
Southern Oregon University (Ashland)
Oregon Institute of Technology - OIT (Klamath Falls or Wilsonville)
Oregon State University (Corvallis or Bend)
Portland State University (Portland)
Linn Benton Community College (Albany, Lebanon and Corvallis)
Chemeketah Community College (Salem)
George Fox University (Newberg)
Pacific University (Forest Grove)
Lewis and Clark (Portland)
Willamette University (Salem)
Corban University (Salem)
Linfield University (McMinville)
Reed College (Portand)
University of Oregon (Eugene)
I am interested in attending an out-of-state college
Other:
Q11: Do you have a career goal? (Example: I want to be an architect.) *
Yes
No
If yes, what is your current career goal or the career that you are most interested in right now? [short answer]
Q12: Please check which career pathway area(s) you are most interested in pursuing (check all that apply):
Architecture or Engineering
Arts (Graphic design, photography, art, performance, theater, etc)
Education
Business or Financial
Computers
Math
Farm, Fishing, Forestry
Food Prep or Service
Healthcare or Medical Field (Doctor, nurse, CNA, dentist, audiologist, physical therapist, etc)
Installation, Maintenance or Repair
Personal Care or Support (Hair stylist, tattoo artist, daycare worker, flight attendant, etc)
Legal Services
Life or Physical Science
Office or Administrative Support
Management
Production (Making products, or overseeing others in manufacturing products) Protective Services (Law enforcement, fire fighter, detective, etc)
Sales
Science
Social and Community Services (Counselor, social worker, addictions therapist, mental health worker, pastor, clergy, etc)
Social Sciences (Historian, geographer, economist, etc)
Trades (Welding, CADD, mechatronics, non-destructive Testing, electrician, etc)
Other:
Personal Needs
Q13: I have at least one friend that I can talk to about my problems. [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Q14: I have at least one trusted adult I can talk to about my problems. [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Q15: I need clothes for school and would like help getting them. [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Q16: My family could use help with making sure we have enough food. [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Q17: My family could use help to get health insurance. [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Personal and Emotional Health
Q18: What health problems or needs have you had in the past year? [Select all that apply]
Depression
Headaches
Stress
Toothaches or dental problems
Frequent bruising or bruises easily
Frequent colds/fevers
Skin problems or rashes
Concern for sexual health or sexually transmitted infections (STIs)
Often being really tired
Irregular periods (i.e. heavy flow, painful, or sporadic)
Diarrhea or vomiting
Problems with eating or weight
Injuries or accidents
Grief
Stomachaches
Anxiety
Thoughts of harming yourself or others
Other:
Q19: Where do you regularly go for health care? [Check all that apply]
Family doctor
Do not have family doctor
Dentist
Do not have dentist
Mental health provider
Specialist
Clinic (community clinic or public health)
Urgent Care/QuickCare
Emergency room
Other:
Q20: Select all reasons that have prevented you from getting medical, dental, or mental health services for yourself [Check all that apply]
Transportation
Cost
No insurance
Do not have a regular doctor
No one to take me
Hours not good for me
Hard to schedule an appointment
Afraid/anxious to seek help
Unsure how to seek help
Other:
Q21: What is the most important health issue facing you and your peers? [short answer]
Q22: I would like to talk with a District Nurse [select one]
Yes
No
Maybe
Q23: I think I might be struggling with: [check all that apply]
Anxiety
Depression
Anger
Grief
Hopelessness
None of the above
I would prefer not to answer
Q24: I could use support with handling my anxiety [Likert Scale 1=No, I don’t need any support; 5= Yes, I need more support]
Q25: I could use support with handling my depression/sadness [Likert Scale 1=No, I don’t need any support; 5= Yes, I need more support]
Q26: Sometimes I wonder if I am in an unhealthy relationship [select one]
Yes
No
I would prefer not to answer
Q27: Sometimes I wonder if I might have an issue with nicotine, alcohol, or drugs [select one]
Yes
No
I would prefer not to answer
Q28: I have someone in my life who has problems with alcohol or drugs [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Q29: I could use some support regarding my gender identity or sexual orientation [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Q30: Sometimes I wonder if I might have an eating disorder [select one]
Yes
No
I would prefer not to answer
Q31: I am concerned about my body image, I am very self-conscious [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Risk Assessment
Q32: I have had thoughts about suicide in the last two months (60 days) [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Q33: I have had thoughts about suicide in the past year (12 months) [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Q34: I am hopeful and feel good about my future [Likert Scale 1=Not at all true for me; 5= Completely true for me]
Q35: In the past year, I have told a friend who was considering suicide to get help from an adult [select one]
Yes
No
I would prefer not to answer
Q36: I have engaged in acts of self-harm in the last 12 months [select one]
Yes
No
I would prefer not to answer
Q37: I would tell an adult about a friend who was suicidal, even if that friend asked me to keep it secret. [Likert Scale 1=Strongly Disagree; 5= Strongly Agree]
Q38: Someone important to me died in the past year [select one]
Yes
No
I would prefer not to answer
Q39: I am interested in talking to someone about my problems [select one]
Yes
Maybe/I would like to learn more
No
I would prefer not to answer
Q40: I am interested in talking to peers who have similar problems [select one]
Yes
No
Maybe/I would like to learn more
I would prefer not to answer
Q41: If interested in talking to peers with similar problems, what kind of group would you be interested in participating in? [select all that apply]
Anger/Anger management
Grief
Anxiety
Depression
Victims of abuse
Healthy Relationship
Trauma
Gender and Identity
Substance abuse
None
other
Q42: What coping skills help you? [select all that apply]
Talking to trusted adults
Healthy activities
Helping others- practicing generosity
Positive friends
Family (or chosen family) support
Spirituality- traditions, practices, culture or religion
I need help finding coping skills that will help me
Other: