SCC: Smoketown Next Gen Services Form

SCC: Smoketown Next Gen Services Form

Afterschool & Summer Program
Group ServicesIndividual ServicesSelf Esteem/ HHS Peer ScaleJustice FormVictimization FormCase NotesOutcomes - NOT READY YET

SMOKETOWN NEXT GENERATION Self Esteem/ HHS Peer Scale
Staff Name:*

First NameLast Name
Staff Email*
You will receive a copy of submission.
Participant Name*

First NameLast Name
Date:*

MonthDayYear
Date
Answer the following questions using this scale:

1 Not True 2 3 4 Somewhat True 5 6 7 All True
I am good at making friends. *
I help other people.*
I ask others if I can be of help.*
I do nice things for people.*
HHS- Peer
Best describe how you feel about the sentence. These questions are designed to find out how you generally feel when you are in school. There are no right or wrong answers.

a= Strongly Disagree

b= Disagree

c= Agree

d= Strongly Agree
I have at least as many friends as other people my age.*
I am not as popular as other people my age.*
In the kinds of things that people my age liketo do, I am at least as good as most other people.*
People my age often pick on me.*
Other people think I am a lot of fun to be with.*
I usually keep to myself because I am not like other people my age.*
Other people wish that they were like me.*
I wish I were a different kind of person because I would have more friends.*
If my group of friends decided to vote forleaders of their group, I'd be elected to a high position.*
When things get tough, I am not a person whomother people my age would turn to for help.*
HSS Family Section
In the blank provided, please write the letter of the answer that best describes how you feel about the sentence. These sentences are designed to find out how you generally feel when you are with your family. There are no right or wrong answers.
My parents are proud of the kind of person I am.*
No one pays much attention to me at home.*
My parents feel that I can be depended on.*
I often feel that if they could, my parents would trade me in *
My parents try to understand me. *
I often feel that if they could, my parents would trade me in *
My parents expect too much of me. *
I am an important person to my family.*
I often feel unwanted at home. *
My parents believe that I will be a success in the future.*
I often wish that I had been born into another family.*

SMOKETOWN NEXT GENERATION Justice Form
Staff Name:*

First NameLast Name
Staff Email*
You will receive a copy of submission.
Name of Participant:*

First NameLast Name
Date of Incident:*

MonthDayYear
Date
Type of Offense*
Outcome of Incident*

SMOKETOWN NEXT GENERATION Victimization Form
Staff Name:*

First NameLast Name
Staff Email:*
You will receive a copy of submission.
Name of Participant:*

First NameLast Name
Age of Participant:*
Date of Incident:*

MonthDayYear
Date
Type of Incident:*
Notes

SMOKETOWN NEXT GENERATION CASE NOTES
Staff Name*

First NameLast Name
Staff Email*
example@example.com
Name of Participant*

First NameLast Name
Date*

MonthDayYear
Date
CASE NOTES*

OUTCOMES- DO NOT USE THIS FORM YET
Staff Name

First NameLast Name
Staff Email
example@example.com
Participant Name

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

SCC: Smoketown Next Gen Services Form

SMOKETOWN NEXT GENERATION GROUP SERVICES

SMOKETOWN NEXT GENERATION INDIVIDUAL SERVICES

SMOKETOWN NEXT GENERATION Self Esteem/ HHS Peer Scale

HHS- Peer

HSS Family Section

SMOKETOWN NEXT GENERATION Justice Form

SMOKETOWN NEXT GENERATION Victimization Form

SMOKETOWN NEXT GENERATION CASE NOTES

OUTCOMES- DO NOT USE THIS FORM YET