Free Wellbeing Screening Template
Rate mood, sleep, appetite, focus, withdrawal and worry on a 1-5 scale, get an AI PDF flag list for a pastoral conversation - never a diagnosis.
Quick answer
Rate mood, sleep, appetite, focus, withdrawal and worry on a 1-5 scale, get an AI PDF flag list for a pastoral conversation - never a diagnosis.
About this template
This is an early-flag tool for a school pastoral team, nothing more. Items rated on a 1-5 scale across mood, sleep, appetite, concentration, withdrawal and worry produce a personalized AI PDF flag list: which areas stand out, what to ask about in a conversation, and what to escalate to safeguarding. It does not diagnose, does not assess risk on its own, and must never replace a qualified referral - a high flag means a person in training makes contact, and your safeguarding process decides the next step.
Live Preview
Fillable sample wellbeing screening preview, showing the rated items and the personalized AI report each respondent gets.
What's Included
Everything you need to run this template.
Indicators, not verdicts
Rated items flag areas for a conversation; they are not a diagnosis.
Protective factors too
What helps is recorded beside what worries.
Route written on the record
The escalation field names who to tell, today.
Conversation starter
The flag list shapes what the adult asks, not what they conclude.
How It Works
From copy to deliverable in four steps.
Set the dimensions and bands
Copy it in and set items alongside your safeguarding route.
Check in with the student
An adult they trust administers or supervises the form.
Read the flags
Use the AI PDF as a conversation list, not a label.
Escalate per policy
A high flag goes to trained staff; risk is handled by your process.
Who Is This For
Pick your role — see how it fits your workflow.
Pastoral and welfare teams
Standardize check-ins without pretending to diagnose.
Form tutors and counselors
Open a conversation with the student's own answers.
Designated safeguarding leads
Receive flagged records through a named route.
Key Features
What makes this template work as a professional deliverable.
- Mood, sleep, appetite, focus, withdrawal and worry rated
- Onset and change-over-time fields
- Protective factors recorded alongside concerns
- AI PDF flag list for the pastoral team
- Escalation and contact fields on the same record
- Consent and data-handling note per entry
Sample Questions Inside
A preview of the real scored items - the published template weights them and writes one report per respondent.
- In the last two weeks I have felt low or flat (1-5)
- Sleep has changed from usual (1-5)
- Appetite or eating has changed (1-5)
- I can concentrate in lessons (1-5)
- I have withdrawn from friends or activities (1-5)
- Something has been worrying me a lot (1-5)
- What has been happening and for how long (text)
- Who or what helps when things are hard (open)