Reply
Wed 15 May, 2013 05:58 pm
Personal:
1) What is your gender?
[]Male []Female []Other
2) How old are you?
[]13 []14 []15 []16 []17 []18
3) On a daily basis what is your mood on a scale of 1 to 10? 1 being the worst, and 10 being the best.
[]1 []2 []3 []4 []5 []6 []7 []8 []9 []10
4) I often lose interest in activities I usually enjoy.
[]Yes []No
5) I lack interest in anything or anybody.
[]Yes []No
Social:
6) How many friends do you have?
[]0 []1-3 []4-6 []7-9 []10-12 []12+
7) What do you do regularly on weekends?
[]Spend Time Alone []Spend Time with Friends []Party []Spend Time with Family []Other (please specify)
8) Do you feel like you matter to your friends?
[]Yes []No
9) Do you look forward to being with your friends?
[]Yes []No
10) Do you like to stay home / be alone most of the time?
[]Yes []No
11) Do you think that you are a social person?
[]Yes []No
12) Do you feel accepted at school?
[]Yes []No
13) I prefer to spend time in the company of others.
[]Yes []No
Home:
1) What is your home situation?
[]Parents together []Parents separate []Living with Other Relatives []Foster Parents []Single Parent []Other
2) Do you feel like you have a good relationship with your guardian(s)?
[]Yes []No
3) Do you feel like your guardian(s) love you?
[]Yes []No
4) Do you look forward to coming home after being out?
[]Yes []No
5) Do you feel comfortable talking to your guardian(s) about most things?
[]Yes []No []Depends on Which Guardian
6) Do you feel accepted at home?
[]Yes []No
7) My living situation is very stressful.
[]Yes []no
Education:
1) Are you attending high school?
[]Yes []No
2) If yes what grade are you in?
[]9 []10 []11 []12
3) What are your average grades if you are in school?
[]100-90 []90-80 []80-70 []70-60 []60-50 []below 50
4) Do you have trouble concentrating or focusing in class?
[]Yes []No
5) Do you feel like school is a constant struggle for you?
[]Yes []No
6) Do you feel that the classes that you are in are too hard for you?
[]Yes []No
7) Do you look forward to going to school?
[]Yes []No
8) I enjoy participating in class.
[]Strongly Agree []Agree []Neither []Disagree []Strongly Disagree
9) I feel my life is very stressful at school.
[]Yes []No
10) Do you feel like you will need to drop out of high school?
[]Yes []No
11) Do you plan to attend college/university?
[]Yes []No