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Survey Form
Age
Please Select
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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59
60
61
62
63
64
65
66
67
68
69
70
Years
Grade
School
I am
Male
Female
Please circle the number that represents your situation.
Agree
Disagree
I am respected at home.
5
4
3
2
1
I give respect to others in my family.
5
4
3
2
1
I am heard and understood at home.
5
4
3
2
1
My parents understand me.
5
4
3
2
1
I understand my parents.
5
4
3
2
1
My family appreciates my efforts and contributions.
5
4
3
2
1
I have a secret that I will never tell anyone.
5
4
3
2
1
I get overwhelmed more than once a month
5
4
3
2
1
I am doing well in school or work
5
4
3
2
1
My friends are supportive of my needs.
5
4
3
2
1
I get support from my family whenever I need it.
5
4
3
2
1
There is an adult that listens to me without judgment.
5
4
3
2
1
My parents set rules that are fair
5
4
3
2
1
Your friends or peers struggle with:
Agree
Disagree
Alcohol use
5
4
3
2
1
Drug use
5
4
3
2
1
Self-esteem
5
4
3
2
1
Body Image
5
4
3
2
1
Peer Pressure
5
4
3
2
1
Eating disorders
5
4
3
2
1
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