Student Wellness Check-In Form

Student Wellness Check-In Form — Form Fields

This education template includes 7 fields. Collect regular wellness check-ins from students to help counselors monitor mental health and wellbeing. Free to customize and use on ZenBuild.

• First Name (text, required)
• Grade or Year (text, required)
• How are you feeling overall this week? (rating, required)
• I have been experiencing (check all that apply) (checkboxes, optional) — options: Stress about schoolwork, Anxiety, Difficulty sleeping, Loneliness, Family concerns, Difficulties with peers, Nothing significant
• Would you like to speak with a school counselor? (multiple choice, required) — options: Yes, No, Maybe later
• Is there anything specific you'd like support with? (long text, optional)
• Is this okay to share with your counselor? (multiple choice, required) — options: Yes, No