Assessment Question Sheet
Question for Student
Simplified Question
Use with grades PK-2, English
Language Learners, or students with
disabilities
a. Can you describe or identify for me a
situation that happens during the
school day that upsets you, or makes
it difficult for you to stay focused on
your work? (Ask for 3 examples.)
b. How does this make you feel?
a. Tell me about something that upsets
you at school or makes it hard for
you to do your work. (Ask for at least
three examples.)
c. Can you describe some different
strategies to deal with this situation?
d. Which strategy do you think would be
the best for the situation you
described? Why would it be the best?
e. Which strategy is the one you actually
use when this happens?
Examples of
Student Responses
Observation Category
with suggested
grade-based
modifications
a. Classmate annoys them;
teacher cold calls them.
b. Angry, nervous, anxious,
fearful; sweating, rapid
heartbeat, shortness of
breath
Social/Emotional
Identification
c. What are some things you can do
when this happens?
d. Which of these do you think is the
best thing to do? Why?
c. Deep breathing, stretching,
physical exercise, change of
activity
d. I think if I go do something
else I will stop being mad at
her (verbal).
Strategy Identification
e. What do you really do when this
happens?
e. I play with someone else.
Strategy Implementation
b. How do you feel when this happens?
K-1: pictures of situations
2-4: verbal or drawing
5+ : verbal
K-1: picture identification
then verbal explanation.
2-4: pictures and verbal
5+: verbal
K-1: pictures
2-4: pictures or verbal
5+: verbal
f. You said that [response to d, above]
would be the best strategy for this
situation. What are the important
steps to apply when you use this best
strategy?
g. When you use this strategy, what is
the result?
h. Is this strategy successful for you?
Why or why not?
i. Do you think you can use this strategy
when these situations occur for you in
the future?
j. Why or why not?
f. You said that [strategy named in d,
above] would be the best thing to do.
What are the important steps to
remember when you do this?
f. Look around the class and
see if I can move to another
table. Stay calm, keep
breathing deeply.
g. What happens when you do this?
g. I don't get in trouble.
h. Does it make your bad feeling go
away? Why or why not?
i. Do you think you can do this the next
time this problem happens for you?
Why or why not?
h. Yes, because I think about
something else.
i. Yes, I think I can. Because I
know it helps me.
Strategy Evaluation
K-1: drawing result
2-4: drawing or verbal
5+: verbal
North River Collaborative – DDM – Counselors and Social Workers 16
STUDENT ID:________________ GRADE:_______ COUNSELOR NAME:____________________________________ DATE:________________________
Mental Health Rubric
In a counseling setting, students identify and/or describe social/emotional challenges that they encounter and
identify, implement, and process/reflect on relevant coping strategies.
No
Evidence of Use
Inconsistent
Evidence of Use
Somewhat Consistent
Evidence of Use
Consistent
Evidence of Use
0
4
7
12
0
4
8
13
0
4
7
12
0
4
8
13
0
8
15
25
0
2
3
5
Total
Score
Social/Emotional Identification
a. Student describes or identifies social/emotional challenge he or she is
encountering.
Student Response/Notes
b. Student describes or identifies feelings or physical responses related
to social/emotional challenge.
Student Response/Notes
Strategy Identification:
c. Student identifies appropriate coping strategies.
Student Response/Notes
d. Student matches a particular strategy with a challenge.
Student Response/Notes
Strategy Implementation
e. Student applies appropriate coping strategies to challenge identified.
Student Response/Notes
Strategy Evaluation
f. Student recalls steps of applied coping strategies.
Student Response/Notes
North River Collaborative – DDM – Counselors and Social Workers 17
g. Student describes and/or identifies outcome of applied coping
strategies
0
2
3
5
0
2
3
5
0
2
3
5
0
2
3
5
Student Response/Notes
h. Student evaluates success of applied coping strategy
Student Response/Notes
i. Student decides if coping strategy can or cannot be applied in future
situations.
Student Response/Notes
j. Student provides a reason for decision as to whether a coping
strategy can or cannot be applied in future situations.
Student Response/Notes
Total Score (100 total possible points)
Describe any accommodations provided and the reasons these were provided:
Record the number of counseling sessions since the last assessment:
INDIVIDUAL sessions _______
GROUP sessions_______
North River Collaborative – DDM – Counselors and Social Workers 18