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Advantage Academy --Needs Assessment
Please take the time to read each statement carefully and circle the most honest answer as it applies to you.
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* Indicates required question
Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Grade
*
What grade are you in?
6
7
8
Freshman
Sophomore
Junior
Senior
Gender
*
Female
Male
I tend to disrupt classes (either intentionally or unintentionally).
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I act without even thinking first.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
It is easy for me to pay attention in class
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I have trouble turning in assignments on time, or remembering to turn them in on time.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I get in trouble more often than my peers.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
People have called me a bully.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I know the rules, but I break them anyway.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
When I feel triggered I will sometimes do things that annoy or provoke others.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I have been in trouble for physical aggression (fighting).
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I have trouble making new friends.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I tend to lose my temper quickly.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I feel like bad things happen to me more often than good things.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I feel like I don’t have many true friends.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
When I feel triggered I will cope or calm myself down with drugs and/or alcohol.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
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