Oak Street Weekly Check-In Sheet
Oak Street Academy
Weekly Check-In Sheet
Alternative Education Program
Student:
Date:
1
Reflection on the Past Week
Rate your overall past week on a scale of 1 to 10:
Rating (1-10):
Challenging
1 2 3 4 5 6 7 8 9 10
Successful
1 = Extremely Challenging / Unproductive 5 = Moderate / Okay 10 = Outstanding / Highly Successful
Briefly explain why you chose this rating:
2
Heart & Mind Check-In
Overall Mood Rating Scale (1 to 10)
Horrible
1 2 3 4 5 6 7 8 9 10
Happy
1 = Horrible / Extremely Overwhelmed / Anxious 5 = Neutral 10 = Very Happy / Everything is Fabulous
Are you feeling overwhelmed in any of the following areas?
School?
Low
1 2 3 4 5
High
Work?
Low
1 2 3 4 5
High
Personal Life?
Low
1 2 3 4 5
High
If yes or somewhat, why?
Do you have someone you can talk to for support?
[ ] Yes [ ] No
I have healthy ways of coping with stress/anxiety:
Disagree
1 2 3 4 5
Agree
List coping strategies you use:
Something I am looking forward to:
Coping Menu
Positive ways to handle heavy stress days:
- 🎵 Music: Energetic or calming beats
- 🏃♂️ Movement: Walking or work-out
- 💨 Breathing: 4-7-8 counts to settle
- 🗣️ Talk: Chat with a friend or advisor
- 🎨 Create: Draw, sketch, or journal
Reach out if you need support!
Oak Street Academy • Student Mentor Packet Page 1 of 2
Planning & Goal Setting
Balance your academic targets, work hours, and lifestyle schedules.
Page 2 Goals
3
Priority Goals for the Upcoming Week
Identify three key goals you commit to achieving before our next meeting:
1
Goal:
By Date:
2
Goal:
By Date:
3
Goal:
By Date:
4
Weekly Schedule (Thursday – Tuesday)
Fill in scheduled obligations like school, work shifts, or personal plans.
Thursday Date: ________
Friday Date: ________
Saturday Date: ________
Sunday Date: ________
Monday Date: ________
Tuesday Date: ________
5
Upcoming Work & Assignments Due
Subject
Upcoming Work / Assignment Details
Due Date
Math
English
Science
Social Studies
6
Teacher / Advisor Notes (Wednesday Meeting)
Advisor Signature:
Next Check-In:
Oak Street Academy • Student Mentor Packet Page 2 of 2