Self-Assessment Worksheet

Take a few moments to reflect on how you’re feeling right now. Answer each question honestly. Use the space provided to write your thoughts.

1. Stress Level (1 = not stressed, 10 = extremely stressed)
   • My current stress rating: _____
   
   
   
   
   
   
2. Mood Check-In
   • Describe how you’re feeling emotionally today. What words come to mind?
   
   
   
   
   
   
   
   
   
   
   
   
3. Sleep Reflection
   • Hours of sleep last night: _____
   • On a scale of 1–10, how restful was it? _____
   
   
   
   
   
   
   
   
   
   
   
   
4. Energy Level
   • Rate your current energy (1 = very low, 10 = very high): _____
   • What factors are influencing your energy right now?
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
5. Recent Stress Triggers
   List up to three situations or events that have caused you stress recently. Briefly explain why each was challenging.

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6. Coping Strategies Review
   For each strategy you’ve tried before, rate its effectiveness (1 = not helpful, 5 = very helpful) and add any notes.Strategy: ____________________________ Effectiveness: ___ Notes:
   
   
   
   
   
   
   
   
   
   
   
   
7. Support Network
   Who can you turn to for help or to talk with when you’re feeling stressed? List names/roles.
   
   
   
   
   
   
   
   
   
   
   
   
8. Additional Reflections
   Any other thoughts, concerns, or observations you’d like to record below:
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

Coping Strategies Reference Sheet

This sheet offers a variety of evidence-based techniques you can use to manage stress, calm your mind, and boost your mood. Experiment with several strategies and note their effectiveness on the Self-Assessment Worksheet.

1. Deep Breathing

• How it works: Slow, controlled breaths activate your body’s relaxation response.
• Try this: Inhale deeply for a count of 4, hold for 2, exhale for 6. Repeat for 3–5 minutes.

2. Progressive Muscle Relaxation

• How it works: Tensing and releasing muscle groups reduces physical tension.
• Try this: Starting at your toes and moving up, tense each muscle group for 5 seconds, then release and notice the difference.

3. Mindfulness Meditation

• How it works: Focusing on the present moment helps quiet racing thoughts.
• Try this: Sit comfortably, close your eyes, and pay attention to your breath. When your mind wanders, gently bring it back.

4. Journaling

• How it works: Writing down worries and reflections can help you process emotions and spot patterns.
• Try this: Spend 5 minutes writing freely about what’s on your mind—no edits, just let your thoughts flow.

5. Physical Activity

• How it works: Exercise releases endorphins, natural mood lifters, and reduces stress hormones.
• Try this: Go for a brisk walk, do a quick HIIT routine, or stretch for 10 minutes—whatever feels doable today.

6. Visualization

• How it works: Imagining a peaceful scene can lower stress and promote deep relaxation.
• Try this: Close your eyes and picture a calm place—focus on sensory details like sounds and smells for 2–3 minutes.

7. Grounding Techniques

• How it works: Engaging your senses anchors you to the present and breaks the cycle of anxious thoughts.
• Try this (5-4-3-2-1): Name 5 things you see, 4 you can touch, 3 you hear, 2 you smell, and 1 you taste.

8. Social Connection

• How it works: Talking with a friend or trusted adult offers emotional support and perspective.
• Try this: Reach out via text, call, or meet in person—share how you feel and listen to their experiences too.

9. Time Management & Breaks

• How it works: Structuring your tasks and taking regular breaks prevents overwhelm.
• Try this: Use the Pomodoro Technique—25 minutes of focused work, then a 5-minute break; repeat.

10. Positive Self-Talk

• How it works: Challenging negative thoughts and reframing them builds resilience and self-confidence.
• Try this: When you notice a self-critical thought, pause and ask: “What would I say to a friend?” Replace it.

Keep this sheet handy. In your next check-in, we’ll review which strategies you tried and how they worked for you.

Personal Goal-Setting Template

Use the SMART framework below to create 1–2 clear goals that will help you manage stress and support your well-being over the next week or two. Write as much detail as possible to make each goal actionable.

Goal 1

What is your goal?
(Write a brief sentence describing what you want to accomplish.)
__________________________________________

Specific
Who is involved? What exactly will you do? Where? Why?
__________________________________________

Measurable
How will you measure progress or know when it’s done?
__________________________________________

Achievable
Is this goal realistic given your time and resources? What steps will you take first?
__________________________________________

Relevant
How does this goal connect to your mental health needs or priorities?
__________________________________________

Time-Bound
By what date or time frame will you complete this?
__________________________________________

Action Steps
List 2–3 specific actions you will take to work toward this goal:

1. ________________________________
   
   
2. ________________________________
   
   
3. ________________________________
   
   

Check-In Date
When will you review your progress?
__________________________________________

Goal 2 (Optional)

Follow the same SMART prompts above if you’d like to set a second goal. If not, leave this section blank.

What is your goal?
__________________________________________

Specific
__________________________________________

Measurable
__________________________________________

Achievable
__________________________________________

Relevant
__________________________________________

Time-Bound
__________________________________________

Action Steps

1. ________________________________
   
   
2. ________________________________
   
   
3. ________________________________
   
   

Check-In Date
__________________________________________

Mind Check-In Script

Introduction & Warm-Up (5 minutes)

Teacher: "Hi [Student Name], thanks for meeting with me today. I’m really glad we have this time just for you. Our goal is to support your mental well-being by checking in on how you’re feeling, exploring ways to manage stress, and setting a practical goal you can work on this week. Everything you share stays between us, so feel free to be open and honest. Does that sound good to you?"

Teacher: "Here’s what we’ll do together:

1. Reflect on your current well-being.
2. Explore coping techniques.
3. Set a SMART goal for next week.

We’ll move at a comfortable pace, and you can ask questions at any time. Let’s get started!"

Self-Assessment Reflection (10 minutes)

Teacher (Hand student the worksheet): "I’m giving you the Self-Assessment Worksheet. Take about five minutes to fill it out. Be honest—this is for you. I’ll step back while you write, and then we’ll talk through your responses."

(After five minutes)

Teacher: "Thanks for sharing. I notice you rated your stress level as a ____. Can you tell me what kinds of situations or thoughts are contributing to that number?"

Teacher: "You mentioned you slept ____ hours last night and rated restfulness as ____. How do you think your sleep is impacting your stress or mood during the day?"

Teacher: "Let’s look at your energy rating of ____. What factors—like classes, work, or other commitments—are influencing how energetic you feel right now?"

Teacher: "You listed these recent stress triggers: ____. Which one feels most challenging, and why?"

Teacher: "On your worksheet, you also noted some coping strategies you’ve tried before. Which one helped the most, and which felt least helpful? What might make a difference next time you use them?"

Coping Strategies Exploration (7 minutes)

Teacher (Open the sheet): "Now I’d like to go over the Coping Strategies Reference Sheet. Take a quick look and let me know which strategies you’ve already tried and how well they worked."

Teacher: "You mentioned you’ve tried journaling and it helped you organize your thoughts. That’s great! How did you feel afterward?"

Teacher: "I also want to introduce two new techniques you haven’t tried yet: deep breathing and grounding with the 5-4-3-2-1 method. For deep breathing, you inhale for 4 counts, hold for 2, then exhale for 6. Would you like to practice a round together now?"

(If yes, guide one cycle)

Teacher: "How was that? The grounding technique asks you to name 5 things you see, 4 things you can touch, 3 you hear, 2 you smell, and 1 you taste. It can help bring your mind back when it’s racing. Would you consider trying that this week?"

Teacher: "Based on our discussion, which two or three strategies—like your favorite journaling plus one or two new ones—do you feel most curious about practicing?"

Personalized Goal-Setting (8 minutes)

Teacher (Hand student the template): "Next, we’ll use the Personal Goal-Setting Template to turn your plan into a SMART goal. What’s one specific activity you’d like to do to manage stress this week?"

Teacher: "Let’s make it Specific: instead of ‘write more,’ perhaps ‘journal for 5 minutes each weekday morning in the kitchen.’ Does that sound doable?"

Teacher: "Measurable: you can check off each day you journal. Achievable: 5 minutes is short enough to fit into your routine. Relevant: you said writing helps you process thoughts. Time-Bound: how about Monday through Friday before second period?"

Teacher: "Please write that in your template. Now, what are 2–3 action steps to make sure you follow through? For example: 1) Set a phone reminder at 7:50 AM; 2) Keep your journal on your desk; 3) Review entries on Friday afternoon."

Teacher: "Great—what date should we set for our check-in to see how this went?"

Summary & Next Steps (End of Session)

Teacher: "To recap, you’ll practice journaling for 5 minutes each weekday morning and try deep breathing anytime you feel stressed. You’ll set a reminder on your phone and keep your journal ready, then we’ll meet again on [Check-In Date]."

Teacher: "I’m really proud of the plan you created. Remember, it’s normal to adjust if something feels off—just let me know. And you can always stop by or send a quick message if you need extra support. You’ve got this!"

Teacher: "Thank you for your honesty and hard work today. I look forward to hearing how these strategies help you feel more in control. See you on [Check-In Date]!"