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Thank you for meeting with me today. During this time, I am going to get to know you better and see if there are any ways I can support you. Sometimes, LYFE students experience challenges at school and at home and I want to make sure you get any support you need personally, as a student, and as a parent. Over the next 30-45 minutes I am going to ask you some questions from the LYFE Student Support Assessment that I ask all students enrolled in LYFE. If at any time you have a question or feel uncomfortable answering questions, please let me know. As a school employee, I am a mandated reporter, which means I may be obligated to share information about you or your child’s safety or well-being with my supervisor or other agencies. I am here to help you with any challenges you have and after the assessment is complete we will work together to get any support you may need.SP Name:DOB/Age:OSIS:Date:What language(s) do you speak? English Spanish French Haitian Creole Other_________________Grade/TASC Level or Program Middle School 9th 10th 11th 12th Pre-TASC TASC Coop TechI. Academic Success: We are going to talk about your academic progress and goals. By answering these questions, I will be able to understand your academic status and plans toward graduation.Academic Content: I will name some academic areas and courses you may be working on at school. For each area, tell me what level of help you need in the subject: No Help, Some Help, or A lot of Help.Subject AreaNo Help Some HelpA Lot of HelpMath English Language Arts (ELA)WritingUS History/Global StudiesScienceForeign LanguagePhysical EducationHealth Test-taking (i.e., Regents, TASC Exam, SATs/ACTs)AttendanceCollege Preparation (e.g., financial aid, personal essay)Other:_____________________Academic Outlook: The next few questions I will ask will help both of us to understand your progress toward graduation, your plans after graduation, and any support you may need. What do you like about your current school? Is there anything you dislike?Are you currently receiving any tutoring at school? Yes NoDo you currently receive any special services or learning accommodations at your school (e.g., 504, IEP, ELL)? Services Receiving:_____________________________ Yes NoHas a guidance counselor reviewed your transcript with you? If yes, when? Yes No Date: Do you understand your transcript and current academic standing? Yes NoHow many credits do you currently have?# of Credits Attained ___________Are you concerned that you may not graduate? Yes NoHigh School students onlyHow many credits do you currently have?# of Credits Attained ___________Pathways to Graduation students onlyHow long have you been at your current P2G/HSE level?What is your P2G/HSE promotional plan?7. What would you like to do when you finish school? College Vocational/Trade School Work Military Service Unsure Other___________________III. Parenting: Getting to know you as a parent and getting to know your child is important. We will now discuss your relationship with your child(ren) and the type of mother/father you wish to be and any assistance you would like. If you are uncomfortable answering any of the questions, let me know. A. Parent-Child Relationship1. What are 3 words that describe you as a parent?2. What are 3 words that describe your child(ren)? B. Parenting SkillsHow much do you agree with these statements?AgreeUnsureDisagreeStudent Declined to Answer I am the kind of mom/dad I want to be for my child(ren)I know how to deal with challenging behaviors or emotions my child(ren) may experiencesdisplayMy emotions can affect my child(ren)I understand how my child(ren) grows and develops over time (e.g., when to sit up, crawl, stand, etc.)I know what healthy foods to feed my child(ren)I know how to tell if something is wrong with my child’s/children’s healthI develop and maintain a daily routine for my child(ren)I feel a bond with my child(ren) through physical such as showing affection and showing that I careMy child’s/children’s mother/father is actively involved in raising our child(ren)Is there anyone else actively involved in raising your child(ren)?Does your child(ren) receive any special services for their developmentearly intervention services to support their development? Yes NoIf yes, describe the services your child(ren) receives and the name of the agency that provides the services:Parenting Services Assessment: I am going to state some services that LYFE students typically ask for help with. Some services can be difficult to obtain and I will support you as best as I can to receive the services you are requesting. If you would like my help with any of these services, let me know. Help with understanding or meeting my child’s/children’s individual or developmental needs Help with managing my child’s/children’s behavior (e.g. tantrums, sleeping patterns) Learning about my rights as a parent Help with my relationship with my child’s/children’s mother/father Help with my relationship with my parent/guardian or the adults that I live withII. Social & Emotional Wellbeing: This section is about your personal, family, and social life and will help me learn and understand more about you, your family, and friends.A. Living ArrangementsWhat borough do you live in? Brooklyn Bronx Manhattan Queens Staten IslandWhere do you live currently? An Apt/House Rented Room Temporarily w/ Friend or Family_____________ A shelter Foster Care/Group Residence Homeless/No Shelter Other_______________How long have you lived there?Who lives in your household with you? Mother Father Foster Mother Foster Father Sister #___ Brother #___ Grandparent(s) Significant Other/Co-Parent Other___________________What are the sleeping arrangements for you and your child where you live?What are the sleeping arrangements for you and your child where you live? Thinking of your space at home, are you able to find personal time for yourself? B. Family & RelationshipsYesNoSometimes Name & Relation to StudentDo you have a parent(s) and/or guardian(s) who can support you while enrolled in LYFE?Do you have a family member who may be interested in participating in LYFE activities and/or groups? If yes, who?Do you have siblings, other family members family or a friend you can count on in times of need?Do you have a friend or person you can count on for emotional support? 54. Are you currently in a relationship?C. Social Connections1. Who do you spend time or socialize with at school? 2. What are your hobbies or special interests?3. Can you tell me about any responsibilities you might have other than school and being a parent?D. Daily Living: This section will help me learn about any concerns you may have about your daily living needs. Sometimes students have personal challenges with their living arrangements or personal needs and I assist them with getting help.Is there ever a worry that…AlwaysUsuallySometimesNeverStudent Declined to Answer You will lose your place to live?Your home is not cool enough in the summer or not warm enough in the winter?Your home does not have heat, hot water, electricity, etc.?You don’t have items for you and your child (e.g., clothing, diapers, formula etc.)??E. Physical & Emotional Safety: It is my job to help keep you and your child(ren) safe, and I would like to ask you some questions about your physical and emotional safety. As I’ve stated already, some of the questions may seem uncomfortable, but it is important that you answer them as honestly as possible so that I can support you if needed. As a reminder, I may be obligated to report any risks to you or your child’s safety. If you feel uncomfortable answering any of these questions, please let me know.YesNoStudent Declined to Answer1. Do you feel safe in your neighborhood?2. Do you feel safe at your school or in your school’s neighborhood?3. Do you ever feel unsafe with the people in your life, either emotionally or physically? (e.g., Does anyone say mean things to you or physically harm you or your child. Are you afraid of anyone? Do you have an order of protection against anyone?)4. Are you or have you ever been in a relationship you do not wish to be in?F. Emotional Wellness: I will make some statements about emotions that students experience in their day-to-day life. For each statement, tell me how often you feel these emotions. If you do not feel comfortable responding to any of these statements, please let me know.I feel….AlwaysSometimesNeverStudent Declined to AnswerI feel positive/hopefulI feel energeticI feel happyI feel sadI feel angryI feel overwhelmedI feel anxious/nervousI feel irritated/annoyedI feel impatient/restlessI feel tiredHave you ever received counseling, support groups or other services? Yes NoIf yes, describe the type of services you received and when you received the services?Would you like to receive counseling or other services for a challenge you are experiencing? Yes NoIf yes, describe the type of support you would like to receive?G. Social & Emotional Services Assessment: I am going to state some services that LYFE students typically ask for help with. If you would like my help with any of these services, let me know. Some services can be difficult to obtain and I will support you as best as I can to receive the services you are requesting. Support with legal issues me or my family is experiencing Support with reuniting with my family Immigration services Housing services or assistance Financial resources (e.g., public assistance or health/medical benefits) Service for a health issue I am experiencing Services for sexual health or birth control options Information about sexual orientation or identity Services for alcohol, substance, or drug use Information about healthy relationships (intimate, family, social etc.) Other ................
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