COLLEGE MOCK FOLDER_LEFT 2021-2022

You can either obtain pre-pronged folders, add prongs to folders with a 2-hole
puncher, or staple your docs inside the folder. Do not use paper clips to secure your
docs inside the folder for submission.

Write your student’s name or
use a folder label.

THE FOLLOWING SHEETS
GO ON THE LEFT SIDE OF YOUR

FOLDER IN THAT ORDER.

ON THESE SHEETS, LOOK FOR THE BRIEF
HIGHLIGHTED GUIDANCE TO READ.

REVIEW THE STUDENT
FOLDER CHECKLIST FOR

FULL DETAILS.

REMEMBER… wherever you
write/type the Student ID, you must

add the prefix to the ID (the ID is
always 9 digits long for
CIS documentation).

LEFT SIDE OF FOLDER

Student Folder Checklist 2021-2022

Student Name: ____J_o_s_i_e__S__c_h__m_o______________________________
Student ID: ___7_7_7__3_4__3_5__6_7___________________________________

Left Side of the Folder

__________ 1. Student Folder Checklist (THIS FORM)
__________ 2.
__________ 3. Student Recommendation (Optional; Only if Received on Paper)
__________ 4.
__________ 5. Consent/Release of Information (Original Mandatory)

Student Profile

Registration, Assessment, and Service Plan Summary (Print Out From
Bluebonnet – “Student Registration and Assessment Information” Report)

__________ 6. End of Year Outcome Form (Print Out From Bluebonnet – “Student Outcome”

Report)

__________ 7. Student Survey Score Report and Responses (Print Out Emailed Report if

Administered Digitally)

__________ 8. ___6_0_%_____ Pre
___5_8_%_____ Post
CIS Staff Faculty Survey (Print Out Emailed Report if Administered Digitally)

___5_9______ Pre
___6_0______ Post

Right Side of the Folder

__________ 1. Service Logs (Print out Completed Service Logs from Bluebonnet at

Outcomes Only)

__________ 2. Grade Reports from Campus Database (Most Recent On Top)

No other information, aside from what is listed above, may be included
in this folder, unless specifically authorized by the Director of Q&S.

LEFT SIDE OF FOLDER

__x__ Fall 2021
____ Spring 2022

LSC-Tomball 999-835
Student Recommendation Form

Campus Name and Code: _L_S__C_-__T_o__m__b_a_l_l___9_9__9_-__8_3__5___ Student ID: __7_7__7_3__4_3__5_6__7_________

Student First Name: ___J__o_s_i_e__________________ Last Name: ___S_c__h_m__o____________ COLLEGE

Please let us know why you were referred to us today. Provide as much information as possible to assist in determining how CIS can better
serve you. Please be aware that you may be served at school or referred to an outside agency for services.

 Academics (Course work, Academic Readiness, Participation)__________________________________________________________

_________

 Attendance (Absences, Tardies)

________________________________________________________________________________________________

 Behavior (Mental Health, Self-Esteem, Family Conflict, ETC.)

___________________________________________________________________________

 Social Service Needs (Food/Housing, Financial Lit, Health, ETC.)

_________________________________________________________________________

How did you hear about CIS? 01-CIS Staff 03-Self Recommendation 07-Peer 09-Parent

31-Law Enforcement 33-Student Services 35-Professor 37-Campus Administrator
43-Academic Advisor
39-Financial Aid Office41-Learning Center 45-Business Office

32-Other: ____________________________________

Jo Schmo Josie SchmoStudent Signature: ___________________________________ Printed Name: _________________________________ Date:_9__-__2__1__-_2__1_
(Signature must be in ink)
Please submit this form to the CIS office. Thank you.

CIS Use Only

Verbal recommendation taken from (NAME): _____________________________________________________________
Date________________ CIS Staff Initials________________

Follow-up Note: ____________________________________________________________________________
__________________________________________________________________________________________

Kristin Carpenter 10631 9/21/21CIS Staff Signature: _________________________________________ Staff Code:__________________ Date: ______________
(Signature must be in ink)

LEFT SIDE OF FOLDER COLLEGE STUDENT CONSENT / RELEASE OF INFORMATION # CI20-2

Campus Name: ___L_S_C_-_T_o_m_b_a_ll________SS_cc_hh_oo_oo_ll_YY_e_eaarr22002210--22002221 Campus Code: ____9_9_9_-_8_3_5____________

Student Name: ____J_o_s_ie__S_ch_m_o__________________ Student ID:_7_7_7_34_3_5_6_7_____________________

Consent to Participate:

1. I agree to participate in the Communities In Schools (CIS) program for the 2021-2022 school year. The services may include

but are not limited to supportive guidance/counseling, educational support, tutoring, mentoring, enrichment activities,

referrals to other agencies, and other:______________________________.

2. I acknowledge that I will complete surveys and/or assessments administered by CIS to guide service planning and determine

progress.

3. I acknowledge that this consent is voluntary and may be revoked at any time by informing CIS staff, in writing, except that

prior consent will still apply to the extent that agencies have already acted in reliance of it.

4. I agree to participate in field trips and other activities sponsored by CIS. Private transportation may be used in these and

other activities.

5. I give permission for routine or emergency medical or dental treatment by any licensed medical doctor to be provided in the

event of illness or accident if I am unable to do it myself.

Consent to Release of Information:

6. I give permission for CIS to provide and obtain the following information from the College: demographics, grade reports,

attendance records, test scores, class schedules, identification numbers, health-related information, special education

information, interventions and services provided, and other:____________________.

7. I acknowledge that the information provided and obtained may be used to plan and adjust services for me, for tracking and

reporting purposes, and to evaluate and determine the effectiveness of the CIS program.

8. I acknowledge that the records and information released under this consent will be kept confidential to the extent permitted

by law and used only for the purpose indicated.

9. I acknowledge that the release of records under this consent is subject to any limitations placed by federal and state law.

10. I acknowledge that this consent allows release of data for the school year listed above. Data from this year will be retained

for up to five seven years and may be shared during that time for evaluation purposes or to provide services that will help

me.

11. I acknowledge that the records released concerning the student may contain references to other persons (i.e., members of the

student’s family).

12. I understand that the data and information collected on me including documentation of services provided to me is maintained

in a secure computer database and a case file. I authorize CIS to maintain the information provided for the purposes noted

above in the CIS computer database and case file.

13. I acknowledge that I have the right to inspect or obtain a copy of any record released by this consent upon request in writing

to the releasing agency, subject to any applicable copying costs and legal limitations.

14. In addition, I give permission for CIS to provide and/or obtain the above information and other information noted below from

the following individuals or organizations:

_____________________________Individual/Organization _____________________________Individual/Organization

15. I acknowledge receipt of the CIS Participant Rights.

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images

of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS’s use of my image for these and similar

purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not

obligated to compensate me for such use of my image. ☐ YES ☐ NO

My signature below authorizes CIS to provide the above types of information relating or referring to me and to my
school and the released agents (upon appropriate request) and also authorizes CIS to obtain such information from my
school.

I release Communities In Schools and its employees, volunteers, or agents from liability for accidents, injuries, or illnesses
that may occur to me during my participation in the program. I understand that I am voluntarily participating in the
Communities In Schools program.

Name (Please print): ________________J_o_s_i_e__S_c_h__m_o_______________________________________________________
Address: ____13__2_0__R_o_u_n_d_a_b__o_u_t_R_d__. ________________ City: __T_o_m__b_a_ll___________, TX Zip: _7_7__3_7_5__________
☐Cell
PSihgonnaet:u_re_2:_8__1__-__7__9__8__-__8____3__8__3____J__o____S__c__h____m____o_______________________________P__h_o_n_e (TSyigpnea:ture in ☐ Home ☐ Work
must be ink) Date: __9_/_2__3_/_2_1__________

Emergency Contact Name: ___M__o_’n_i_q_u_e_S__c_h_m_o______________________ Phone: __2_8_1_-_7_9__8_-_9_3_9_3_________________
Emergency Contact Relationship to Student: __M__o_m________________________________________________________

CIS Staff Signature: __K__r_is_t_in__C__a_r_p_e_n_t_e_r____________ Staff Code: ___1_0_6__3_1____Date Received: __9_-_2__3_-_2_1_______

© 2019 Texas Education Agency Updated: March 2022 Page 1 of 1

LEFT SIDE OF FOLDER

2021-09-18T08:47:15+00:00 UTC

2021-2022

LSC – Tomball (999-835)

2021-2022

[email protected]

September 29, 2021

Josie
Schmo
(281) 798-8383

343567
1320 Roundabout Road
Tomball
77375

[email protected]

(281) 798-9393
Mo’nique Schmo
Mother

[email protected]

[email protected]

[email protected]

Student Profile 2021-2022 LEFT SIDE OF FOLDER

Campus Name LSC-Tomball

Campus Code 999-835

Student Name (first) Josie Schmo(mi) (last)

COLLEGE

Name of High ____Tomball HS_________ School ___Tomball ISD_____ Year of HS 2022
School: District: Graduation

Student Information Gender 1 Male 7 Female 9 Other Ethnicity (required) Race (select all that apply)
1 American Indian/Native Alaskan
Date of Birth 4 / 27 / 2003 1 Hispanic/Latino 2 Asian
OR
(Check ONE) 1 English 3 Spanish 2 NOT Hispanic/Latino 3 Black/African American
5 Native Hawaiian/Other Pacific Islander
HomeLanguage 6 White
8 Other
5 Vietnamese 9 Other: ___________

The Student Lives WITH: (Check ALL that apply) The Student Lives WHERE: (Check ONLY ONE)
35 Partner or Spouse
1 Immediate Family Home 10 Emergency Shelter
1 Mother 3 Father 3 Other Relative's Home 13 Other Perm. Shelter
5 Motel 15 Detention Facility
7 Grandmother 12 Other Relative 7 Halfway House 21 Non-Relative's Home
9 Residential Placement 23 Homeless
9 Grandfather 16 Legal Guardian 25 Campus Housing

14 Foster Parent 31 Independent

18 Step Parent 33 Non-Relative

Family Information __ Yes __ No : Female Head of Household (Unmarried woman who Number of people living in the household __1__
pays more than 50% of costs for mom and her dependents)

Assistance Special Characteristics 35 Previously Incarcerated
(Check ALL that apply to student and family) (Check ALL that apply) 37 First Generation College Student
39 Disability Services
99 None 4 Migrant Family 41 Employed Full Time
8 Homeless 43 Employed Part Time
4 Public Housing 24 WIA Participant 9 Foster Care 44 Veteran
6 SSI 25 CHIP 10 Physical Disability 30 None
8 Food Stamps 27 Financial Aid 25 Parenting/Pregnant
11 Medicaid 28 Natural Disaster 51 Unschooled, Asylee or Refugee
13 WIC
33 Active Military
50 Immigrant

Student's Country of Origin:

LEFT SIDE OF FOLDER

JOSIE SCHMO LSC - Tomball
999-835
777343567
COLLEGE 2021 - 2022

Student Information Recommendation

SSN/PEIMS/TUID 4/27/2003 Recommendation 9/21/2021
Date of Birth Female Date
Not Hispanic Kristin Carpenter
Gender Other Case Assigned To Self
Ethnicity English Recommendation
Self-Referral
Race Employed Full Time Source Academics
Primary Language Relationship Attendance
Behavior
Special Reason Social Services
Characteristics
Eligibility

Criteria Mental Health

Family Profile Assessment & Service Plan

Lives Where Immediate Family Home Assessment Date 10/1/2021
Number in 1 Educational Goal Enrollment in 4-yr University or
Household College
Lives With Independent
No Barriers To Success Plan
Female Head of
Household Financial Aid Behavior Mental Health 100
200
Public Assistance

Consent & Contact

Consent Date 9/23/2021

Photo Consent Yes

Parent Name Mo’nique Schmo
Address 1320 Roundabout Rd.
Tomball, TX 77375
Contact Number 2817988383

LEFT SIDE OF FOLDER

Communities in Schools Houston, Inc: End of Year Outcome

School Code and Name: 999-835 LSC - Tomball Grade Level: COLLEGE
10/1/2021
Student ID and Name: JOSIE SCHMO (777343567) Assessment Date: N/A

TUID: Update Date:

Assigned To: 10631 Kristin Carpenter

Semester: FALL 2021

Termination Date: 12/31/2021 Reason: 999-End of Semester

Improvement in assessed areas:
1 = improved; 2 = no change; 3 = got worse
*** = Added on Update Date

Behavior Improved

13 Mental Health 1

Did student complete all courses taken with a C or better?
KEY: S=Successfully Completed; U=Unsuccessful Attempt; NA=Not Applicable

S For Credit -- Developmental -- Other
Progress 3 For Credit hours attempted

3 For Credit hours earned

0 Developmental hours earned 0 Developmental hours attempted

3 Total hours earned 3 Total hours attempted

KEY: S=Successfully Completed; U=Unsuccessful Attempt
U 5 - Enrollment in 4-yr University or College
U 7 - Transfer Credit to Another Institution

Kristin CarpenterCIS Staff Signature ________________________________________ Date: 6/3/2022

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, December 14, 2021 11:54 AM
To: Kristin Carpenter
Subject: Student Survey Score Report - Josie Schmo

CAUTION: This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.

Josie Schmo

Tomball
Taken: 9/14/21

Score: 60%

Emotional Wellness

Understanding your own feelings and expressing emotions in a constructive way, and having the ability to deal with stress and cope with life’s
challenges

I am able to maintain a balance of work, family, friends and other obligations.
Sometimes

I am resilient and can bounce back after a disappointment or problem.
Sometimes

I am able to make decisions with minimal stress or worry.
Rarely

I am flexible and adapt or adjust to change in a positive way.
Rarely

I find it easy to express my emotions in positive, constructive ways.
Rarely

I recognize when I am stressed and take steps to manage my stress (e.g., exercise, quiet time, meditation).
Rarely

When I am angry, I try to let others know in non-confrontational or non-hurtful ways.
Sometimes

Environmental Wellness

Recognizing the interactions between yourself and your environment (natural and social), responsibly using available resources, and fostering a
safer and healthier environment for others

I surround myself with people who support me in my journey of being healthy and well.
Rarely

I am aware of and make use of campus health, and wellness, and safety resources.
Rarely

Intellectual Wellness

engaging in creative and mentally-stimulating activities, expanding your knowledge through cultural, artistic, or skill-based learning, and sharing
knowledge and skills with others

I can critically consider the opinions and information presented by others and provide constructive feedback.

Never

I enjoy learning about subjects other than those I am required to study/in my field of work.
Rarely

I manage my time well, rather than it managing me.
Sometimes

Occupational Wellness

Getting personal fulfillment from your job or academic pursuits, and contributing to knowledge and skills, while maintaining a work-life balance

I balance my social life and job responsibilities well.
Sometimes

My work load is manageable.
Sometimes

Physical Wellness

Making choices to avoid harmful habits and practice behaviors that support your physical body, health and safety

I engage in physical exercise regularly (eg 30 minutes at least 5X a week or 10,000 steps daily).
Rarely

I avoid using tobacco products or other drugs.
Sometimes

I abstain from drinking alcohol; or if I do drink, I aim to keep my BAC less than .06.
Usually

I eat a balanced diet (fruits, vegetables, low-moderate fat, whole grains).
Sometimes

I get regular physical exams (i.e. annual, when I have atypical symptoms).
Rarely

I get 6-8 hours of sleep each night.
Rarely

Social Wellness

Building and maintaining a diversity of supportive relationships, and dealing effectively with interpersonal conflict

I participate in a wide variety of social activities and find opportunities to form new relationships.
Never

I feel supported and respected in my close relationships.
Rarely

I consider the feelings of others and do not act in hurtful/selfish ways.
Sometimes

Spiritual Wellness

Having beliefs and values that provide a sense of purpose and help give meaning and purpose to your life, and acting in alignment with those beliefs

I feel like my life has purpose and meaning.
Rarely
I take time to think about what's important in life - who I am, what I value, where I fit in, and where I am going.
Rarely

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, May 14, 2022 11:54 AM
To: Kristin Carpenter
Subject: Student Survey Score Report - Josie Schmo

CAUTION: This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.

Josie Schmo

Tomball
Taken: 5/14/22

Score: 58%

Emotional Wellness

Understanding your own feelings and expressing emotions in a constructive way, and having the ability to deal with stress and cope with life’s
challenges

I am able to maintain a balance of work, family, friends and other obligations.
Sometimes

I am resilient and can bounce back after a disappointment or problem.
Rarely

I am able to make decisions with minimal stress or worry.
Rarely

I am flexible and adapt or adjust to change in a positive way.
Rarely

I find it easy to express my emotions in positive, constructive ways.
Rarely

I recognize when I am stressed and take steps to manage my stress (e.g., exercise, quiet time, meditation).
Rarely

When I am angry, I try to let others know in non-confrontational or non-hurtful ways.
Sometimes

Environmental Wellness

Recognizing the interactions between yourself and your environment (natural and social), responsibly using available resources, and fostering a
safer and healthier environment for others

I surround myself with people who support me in my journey of being healthy and well.
Rarely

I am aware of and make use of campus health, and wellness, and safety resources.
Rarely

Intellectual Wellness

Engaging in creative and mentally-stimulating activities, expanding your knowledge through cultural, artistic, or skill-based learning, and sharing
knowledge and skills with others

I can critically consider the opinions and information presented by others and provide constructive feedback.
Never

I enjoy learning about subjects other than those I am required to study/in my field of work.
Rarely

I manage my time well, rather than it managing me.
Sometimes

Occupational Wellness

Getting personal fulfillment from your job or academic pursuits, and contributing to knowledge and skills, while maintaining a work-life balance

I balance my social life and job responsibilities well.
Sometimes

My work load is manageable.
Sometimes

Physical Wellness

Making choices to avoid harmful habits and practice behaviors that support your physical body, health and safety

I engage in physical exercise regularly (eg 30 minutes at least 5X a week or 10,000 steps daily).
Rarely

I avoid using tobacco products or other drugs.
Sometimes

I abstain from drinking alcohol; or if I do drink, I aim to keep my BAC less than .06.
Usually

I eat a balanced diet (fruits, vegetables, low-moderate fat, whole grains).
Sometimes

I get regular physical exams (i.e. annual, when I have atypical symptoms).
Rarely

I get 6-8 hours of sleep each night.
Rarely

Social Wellness

Building and maintaining a diversity of supportive relationships, and dealing effectively with interpersonal conflict

I participate in a wide variety of social activities and find opportunities to form new relationships.
Never

I feel supported and respected in my close relationships.
Rarely

I consider the feelings of others and do not act in hurtful/selfish ways.
Sometimes

Spiritual Wellness

Having beliefs and values that provide a sense of purpose and help give meaning and purpose to your life, and acting in alignment with those beliefs
I feel like my life has purpose and meaning.
Rarely
I take time to think about what's important in life - who I am, what I value, where I fit in, and where I am going.
Rarely

LEFT SIDE OF FOLDER

Student Survey - Community College

Student Information

First Name*

Josie _________________________________________________

Last Name*

Schmo _________________________________________________

Student ID*

777343567_________________________________________________

Lone Star College Campus*

( ) CyFair
( ) Greenspoint
( ) North Harris
( ) University Park
( ) Tomball
( ) Victory
( ) Fairbanks
( ) East Aldine

Wellness Self-Assessment Never Rarely Sometimes Usually
() () () ()
I am able to maintain a balance of work,
family, friends and other obligations.

Communities In Schools of Houston 2021-2022

I engage in physical exercise regularly (eg 30 () () () ()

minutes at least 5X a week or 10,000 steps

daily).

() () () ()
I avoid using tobacco products or other drugs.

I abstain from drinking alcohol; or if I do () () () ()

drink, I aim to keep my BAC less than .06.

I balance my social life and job () () () ()
responsibilities well.

I participate in a wide variety of social () () () ()

activities and find opportunities to form new

relationships.

I take time to think about what's important in () () () ()

life - who I am, what I value, where I fit in,

and where I am going.

Communities In Schools of Houston 2021-2022

Never Rarely Sometimes Usually

I am resilient and can bounce back after a () () () ()

disappointment or problem.

I surround myself with people who support () () () ()

me in my journey of being healthy and well.

I eat a balanced diet (fruits, vegetables, () () () ()
lowmoderate fat, whole grains).

I can critically consider the opinions and () () () ()

information presented by others and provide

constructive feedback.

I am able to make decisions with minimal () () () ()

stress or worry.

I am flexible and adapt or adjust to change in () () () ()

a positive way.

I find it easy to express my emotions in () () () ()
positive, constructive ways.

I recognize when I am stressed and take steps () () () ()

to manage my stress (e.g., exercise, quiet

time, meditation).

My work load is manageable. () () () ()

I get regular physical exams (i.e. annual, () () () ()

when I have atypical symptoms).

Never Rarely Sometimes Usually
Communities In Schools of Houston 2021-2022

I enjoy learning about subjects other than () () () ()

those I am required to study/in my field of

work.

I get 6-8 hours of sleep each night. () () () ()

I feel supported and respected in my close Never Rarely Sometimes Usually
relationships. () () () ()
() () () ()
When I am angry, I try to let others know in () () () ()
non-confrontational or non-hurtful ways. () () () ()
() () () ()
I manage my time well, rather than it
managing me.

I am aware of and make use of campus
health, and wellness, and safety resources.

I consider the feelings of others and do not
act in hurtful/selfish ways.

I feel like my life has purpose and meaning. () () () ()

Communities In Schools of Houston 2021-2022

LEFT SIDE OF FOLDER

Student Survey - Community College

Student Information

First Name*

Josie _________________________________________________

Last Name*

Schmo _________________________________________________

Student ID*

777343567_________________________________________________

Lone Star College Campus*

( ) CyFair
( ) Greenspoint
( ) North Harris
( ) University Park
( ) Tomball
( ) Victory
( ) Fairbanks
( ) East Aldine

Wellness Self-Assessment Never Rarely Sometimes Usually
() () () ()
I am able to maintain a balance of work,
family, friends and other obligations.

Communities In Schools of Houston 2021-2022

I engage in physical exercise regularly (eg 30 () () () ()

minutes at least 5X a week or 10,000 steps

daily).

() () () ()
I avoid using tobacco products or other drugs.

I abstain from drinking alcohol; or if I do () () () ()

drink, I aim to keep my BAC less than .06.

I balance my social life and job () () () ()
responsibilities well.

I participate in a wide variety of social () () () ()

activities and find opportunities to form new

relationships.

I take time to think about what's important in () () () ()

life - who I am, what I value, where I fit in,

and where I am going.

Communities In Schools of Houston 2021-2022

Never Rarely Sometimes Usually

I am resilient and can bounce back after a () () () ()

disappointment or problem.

I surround myself with people who support () () () ()

me in my journey of being healthy and well.

I eat a balanced diet (fruits, vegetables, () () () ()
lowmoderate fat, whole grains).

I can critically consider the opinions and () () () ()

information presented by others and provide

constructive feedback.

I am able to make decisions with minimal () () () ()

stress or worry.

I am flexible and adapt or adjust to change in () () () ()

a positive way.

I find it easy to express my emotions in () () () ()
positive, constructive ways.

I recognize when I am stressed and take steps () () () ()

to manage my stress (e.g., exercise, quiet

time, meditation).

My work load is manageable. () () () ()

I get regular physical exams (i.e. annual, () () () ()

when I have atypical symptoms).

Never Rarely Sometimes Usually
Communities In Schools of Houston 2021-2022

I enjoy learning about subjects other than () () () ()

those I am required to study/in my field of

work.

I get 6-8 hours of sleep each night. () () () ()

I feel supported and respected in my close Never Rarely Sometimes Usually
relationships. () () () ()
() () () ()
When I am angry, I try to let others know in () () () ()
non-confrontational or non-hurtful ways. () () () ()
() () () ()
I manage my time well, rather than it
managing me.

I am aware of and make use of campus
health, and wellness, and safety resources.

I consider the feelings of others and do not
act in hurtful/selfish ways.

I feel like my life has purpose and meaning. () () () ()

Communities In Schools of Houston 2021-2022

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, October 1, 2021 12:00 PM
To: Kristin Carpenter
Subject: CIS Staff Response Report - Josie Schmo

CAUTION: This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.

Josie Schmo

Tomball
CIS Staff Respondent: Kristin Carpenter
Taken: 10/01/2021

Score: 59

Behavior Performance
Academic Readiness
N/A

Language (ESL/LEP)
N/A

Emotional Crisis Coping
N/A

Mental Health Maintenance
Skills Demonstrated with Minor Mistakes

Grief & Loss Coping
N/A

Family Conflict Management
N/A

Self Esteem
N/A

Social Skills
N/A

Pro Social Skills & Civic Engagement
N/A

Career Readiness
N/A

Financial Literacy
N/A

Life Skills
N/A

Social Service Access
Basic Needs
N/A

Day Care
N/A

Employment
N/A

Health
N/A

Housing
N/A

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, May 17, 2022 12:00 PM
To: Kristin Carpenter
Subject: CIS Staff Response Report - Josie Schmo

CAUTION: This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.

Josie Schmo

Tomball
CIS Staff Respondent: Kristin Carpenter
Taken: 5/17/2021

Score: 60

Behavior Performance
Academic Readiness
N/A

Language (ESL/LEP)
N/A

Emotional Crisis Coping
N/A

Mental Health Maintenance
Skills Demonstrated Consistently without Mistakes

Grief & Loss Coping
N/A

Family Conflict Management
N/A

Self Esteem
N/A

Social Skills
N/A

Pro Social Skills & Civic Engagement
N/A

Career Readiness
N/A

Financial Literacy
N/A

Life Skills
N/A

Social Service Access
Basic Needs
N/A

Day Care
N/A

Employment
N/A

Health
N/A

Housing
N/A

LEFT SIDE OF FOLDER

CIS Staff Survey - Community College Only

Student Information

Student's Name*

Josie Schmo _________________________________________________

Student ID*

777343567_________________________________________________

Campus*
( ) CyFair
( ) Greenspoint
( ) North Harris
( ) University Park
( ) Tomball
( ) Victory
( ) Fairbanks
( ) East Aldine

Respondent Information

Your Name*

Kristin Carpenter _________________________________________________

Your Title*
( ) Program Manager
( ) Service Coordinator
( ) Intern

Communities In Schools of Houston 2021-2022

Behavior Performance

No Skills Some Skills Skills Skills N/A
Demonstrat Demonstrated Demonstrated Demonstrated
Consistently
ed with with Minor
Significant Mistakes without
Mistakes Mistakes

Academic () () () () ()
Readiness
() () () () ()
Language
(ESL/LEP) () () () () ()

Emotional () () () () ()
Crisis Coping
() () () () ()
Mental Health
Maintenance () () () () ()

Grief & Loss
Coping

Family
Conflict
Management

Self Esteem () () () () ()

Social Skills () () () () ()

Pro Social () () () () ()

Skills & Civic

Engagement

Communities In Schools of Houston 2021-2022

Career ( ) ( ) ( ) ( ) ()
Readiness ()
()
Financial () () () ()

Literacy

Life Skills () () () ()

Social Service Access

No Some Access with Consistent N/A
Access Access Minor Access
with without
Significant Limitations
Limitations Limitations

Basic Needs () () () () ()

Day Care () () () () ()

Employment () () () () ()

Health ( ) ( ) ( ) ( ) ( )

Housing () () () () ()

Communities In Schools of Houston 2021-2022

LEFT SIDE OF FOLDER

CIS Staff Survey - Community College Only

Student Information

Student's Name*

Josie Schmo _________________________________________________

Student ID*

777343567_________________________________________________

Campus*
( ) CyFair
( ) Greenspoint
( ) North Harris
( ) University Park
( ) Tomball
( ) Victory
( ) Fairbanks
( ) East Aldine

Respondent Information

Your Name*

Kristin Carpenter _________________________________________________

Your Title*
( ) Program Manager
( ) Service Coordinator
( ) Intern

Communities In Schools of Houston 2021-2022

Behavior Performance

No Skills Some Skills Skills Skills N/A
Demonstrat Demonstrated Demonstrated Demonstrated
Consistently
ed with with Minor
Significant Mistakes without
Mistakes Mistakes

Academic () () () () ()
Readiness
() () () () ()
Language
(ESL/LEP) () () () () ()

Emotional () () () () ()
Crisis Coping
() () () () ()
Mental Health
Maintenance () () () () ()

Grief & Loss
Coping

Family
Conflict
Management

Self Esteem () () () () ()

Social Skills () () () () ()

Pro Social () () () () ()

Skills & Civic

Engagement

Communities In Schools of Houston 2021-2022

Career ( ) ( ) ( ) ( ) ()
Readiness ()
()
Financial () () () ()

Literacy

Life Skills () () () ()

Social Service Access

No Some Access with Consistent N/A
Access Access Minor Access
with without
Significant Limitations
Limitations Limitations

Basic Needs () () () () ()

Day Care () () () () ()

Employment () () () () ()

Health ( ) ( ) ( ) ( ) ( )

Housing () () () () ()

Communities In Schools of Houston 2021-2022