Chess Whitts Forms Page

Mental Health Wellness Check In form
Mental Health Exit Ticket
Your Well-being matters as much as your next move.

First name

Last name

Session #:

PART 1: MOOD & EMOTIONAL STATE

Circle the number that best describes how you feel right now (1= Very, Low 5 = Great)

PART 2 COGNITIVE ENGAGEMENT:

Check all that apply.

Level of mental sharpness

Check all that apply

I learned something new or practiced a new strategy.

I felt more focused during today's session than when i arrived.

I had to think several movs ahead, and I enjoyed it.

I noticed my problem-solving felt stronger today.

PART 3: SOCIAL CONNECTION

Check all that apply

I had a meaningful conversation with someone today.

I felt a sense of belonging in this group.

I helped or encouraged another participant.

Playing chess with others lifted my spirits.

PART 4: WELL-BEING CHECK

Please check any that are true for uou today. All responses are confidential.

I feel less lonely after today's class.

I feel more confident in myself after today.

I felt anxious, sad, or low during the session.

I would like to talk to someone about how i'm feeling.

PART 5: IN YOUR OWN WORDS

One Word to descripe how you feel leaving today's class;

Anything else you'd like us to know? (Optional)

Dr. Karine Clay PhD

702-528-1276