Follow-up survey for 0708 PRDT Student

Project Resiliency Day Treatment Program Student Intake Questions

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Please complete the following as best as you can. Thoughtful completion of this survey will help the Project Resiliency Day Treatment Program staff to develop a more effective support plan for you. All information is kept in agreement with the Freedom of Information and Protection of Privacy Act.

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YOUR KEY CONTACT INFORMATION:

YOUR KEY CONTACT INFORMATION: Name:
School:
Home Address:
Home Phone Number:
City:
Province:
Postal Code:

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HOW IS YOUR HEALTH AND LIVING CONDITIONS?

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HOW ARE YOUR RELATIONSHIPS?

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DO YOU BELONG TO A COMMUNITY?

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WHAT'S IMPACTING YOUR LIFE?

	Never	Monthly	Weekly	All the time (Daily)
Death (or Terminal Illness) of someone close to me.	*WHAT'S IMPACTING YOUR LIFE? Death (or Terminal Illness) of someone close to me. Never	Death (or Terminal Illness) of someone close to me. Monthly	Death (or Terminal Illness) of someone close to me. Weekly	Death (or Terminal Illness) of someone close to me. All the time (Daily)
Witness a Crime	Witness a Crime Never	Witness a Crime Monthly	Witness a Crime Weekly	Witness a Crime All the time (Daily)
Involved in a Crime	Involved in a Crime Never	Involved in a Crime Monthly	Involved in a Crime Weekly	Involved in a Crime All the time (Daily)
Violence	Violence Never	Violence Monthly	Violence Weekly	Violence All the time (Daily)
Moving Primary Residence (Home)	Moving Primary Residence (Home) Never	Moving Primary Residence (Home) Monthly	Moving Primary Residence (Home) Weekly	Moving Primary Residence (Home) All the time (Daily)
Divorce	Divorce Never	Divorce Monthly	Divorce Weekly	Divorce All the time (Daily)
Foster Care	Foster Care Never	Foster Care Monthly	Foster Care Weekly	Foster Care All the time (Daily)
Poverty	Poverty Never	Poverty Monthly	Poverty Weekly	Poverty All the time (Daily)
Mental Illness	Mental Illness Never	Mental Illness Monthly	Mental Illness Weekly	Mental Illness All the time (Daily)
Racism	Racism Never	Racism Monthly	Racism Weekly	Racism All the time (Daily)
Cultural Pressures	Cultural Pressures Never	Cultural Pressures Monthly	Cultural Pressures Weekly	Cultural Pressures All the time (Daily)

Other (please specify)

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Why were you originally referred to Project Resiliency?

Why were you originally referred to Project Resiliency? Drug use/abuse

Alcohol use/abuse

Both drug and alcohol use/abuse

Skipping/attendance

Family issues

other

Other (please specify)

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If you chose drugs or alcohol for the question above, have you

If you chose drugs or alcohol for the question above, have you Stopped using

Reduced use

Maintained the same usage

Increased your use

Additional details

Please comment on how Project Resiliency impacted you or give suggestions for program changes.

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	Yes	No	Doesn't Apply
Do you consider yourself violent?	*HOW IS YOUR HEALTH AND LIVING CONDITIONS? Do you consider yourself violent? Yes	Do you consider yourself violent? No	Do you consider yourself violent? Doesn't Apply
Do you eat three times a day?	Do you eat three times a day? Yes	Do you eat three times a day? No	Do you eat three times a day? Doesn't Apply
Do you get panic attacks or struggle with anxiety?	Do you get panic attacks or struggle with anxiety? Yes	Do you get panic attacks or struggle with anxiety? No	Do you get panic attacks or struggle with anxiety? Doesn't Apply
Do you go to bed the same time every night?	Do you go to bed the same time every night? Yes	Do you go to bed the same time every night? No	Do you go to bed the same time every night? Doesn't Apply
Do you have a place to keep your belongings?	Do you have a place to keep your belongings? Yes	Do you have a place to keep your belongings? No	Do you have a place to keep your belongings? Doesn't Apply
Do you have access to a Dentist?	Do you have access to a Dentist? Yes	Do you have access to a Dentist? No	Do you have access to a Dentist? Doesn't Apply
Do you have access to a Family Doctor?	Do you have access to a Family Doctor? Yes	Do you have access to a Family Doctor? No	Do you have access to a Family Doctor? Doesn't Apply
Do you have access to birth control if you need it?	Do you have access to birth control if you need it? Yes	Do you have access to birth control if you need it? No	Do you have access to birth control if you need it? Doesn't Apply
Do you have access to Laundry?	Do you have access to Laundry? Yes	Do you have access to Laundry? No	Do you have access to Laundry? Doesn't Apply
Do you have breathing difficulties?	Do you have breathing difficulties? Yes	Do you have breathing difficulties? No	Do you have breathing difficulties? Doesn't Apply
Do you have ear/eye difficulties?	Do you have ear/eye difficulties? Yes	Do you have ear/eye difficulties? No	Do you have ear/eye difficulties? Doesn't Apply
Do you have eating difficulties?	Do you have eating difficulties? Yes	Do you have eating difficulties? No	Do you have eating difficulties? Doesn't Apply
Do you have heat and hot water in your home?	Do you have heat and hot water in your home? Yes	Do you have heat and hot water in your home? No	Do you have heat and hot water in your home? Doesn't Apply
Do you have privacy in your home?	Do you have privacy in your home? Yes	Do you have privacy in your home? No	Do you have privacy in your home? Doesn't Apply
Do you have regular Headaches?	Do you have regular Headaches? Yes	Do you have regular Headaches? No	Do you have regular Headaches? Doesn't Apply
Do you have regular Stomach Aches?	Do you have regular Stomach Aches? Yes	Do you have regular Stomach Aches? No	Do you have regular Stomach Aches? Doesn't Apply
Do you have someone to talk to about sex?	Do you have someone to talk to about sex? Yes	Do you have someone to talk to about sex? No	Do you have someone to talk to about sex? Doesn't Apply
Do you have trouble focusing?	Do you have trouble focusing? Yes	Do you have trouble focusing? No	Do you have trouble focusing? Doesn't Apply
Do you have trouble getting prescriptions filled?	Do you have trouble getting prescriptions filled? Yes	Do you have trouble getting prescriptions filled? No	Do you have trouble getting prescriptions filled? Doesn't Apply
Do you hurt or break things during angry outbursts?	Do you hurt or break things during angry outbursts? Yes	Do you hurt or break things during angry outbursts? No	Do you hurt or break things during angry outbursts? Doesn't Apply
Do you limit your "junk" food?	Do you limit your "junk" food? Yes	Do you limit your "junk" food? No	Do you limit your "junk" food? Doesn't Apply
Do you sleep at home every night?	Do you sleep at home every night? Yes	Do you sleep at home every night? No	Do you sleep at home every night? Doesn't Apply
Do you sleep at least 7 hours every night?	Do you sleep at least 7 hours every night? Yes	Do you sleep at least 7 hours every night? No	Do you sleep at least 7 hours every night? Doesn't Apply
Have you been diagnosed with Depression?	Have you been diagnosed with Depression? Yes	Have you been diagnosed with Depression? No	Have you been diagnosed with Depression? Doesn't Apply
Have you ever "Blacked Out"?	Have you ever "Blacked Out"? Yes	Have you ever "Blacked Out"? No	Have you ever "Blacked Out"? Doesn't Apply

	Yes	No	Doesn't Apply
Are drugs more important than friends?	*HOW ARE YOUR RELATIONSHIPS? Are drugs more important than friends? Yes	Are drugs more important than friends? No	Are drugs more important than friends? Doesn't Apply
Are there times when you hate yourself?	Are there times when you hate yourself? Yes	Are there times when you hate yourself? No	Are there times when you hate yourself? Doesn't Apply
Do you care about other people?	Do you care about other people? Yes	Do you care about other people? No	Do you care about other people? Doesn't Apply
Do you get along with brothers/sisters?	Do you get along with brothers/sisters? Yes	Do you get along with brothers/sisters? No	Do you get along with brothers/sisters? Doesn't Apply
Do you have a reliable parent/guardian?	Do you have a reliable parent/guardian? Yes	Do you have a reliable parent/guardian? No	Do you have a reliable parent/guardian? Doesn't Apply
Do you have a role model?	Do you have a role model? Yes	Do you have a role model? No	Do you have a role model? Doesn't Apply
Do you have a supportive extended family (Uncles, Aunts, very close family friends, etc...)?	Do you have a supportive extended family (Uncles, Aunts, very close family friends, etc...)? Yes	Do you have a supportive extended family (Uncles, Aunts, very close family friends, etc...)? No	Do you have a supportive extended family (Uncles, Aunts, very close family friends, etc...)? Doesn't Apply
Do you have any drug related Nicknames?	Do you have any drug related Nicknames? Yes	Do you have any drug related Nicknames? No	Do you have any drug related Nicknames? Doesn't Apply
Do you have drug friends that you don't like?	Do you have drug friends that you don't like? Yes	Do you have drug friends that you don't like? No	Do you have drug friends that you don't like? Doesn't Apply
Do you have support from any of your Teachers?	Do you have support from any of your Teachers? Yes	Do you have support from any of your Teachers? No	Do you have support from any of your Teachers? Doesn't Apply
Do you have supportive Friends?	Do you have supportive Friends? Yes	Do you have supportive Friends? No	Do you have supportive Friends? Doesn't Apply
Do you have the trust of your Grandparents?	Do you have the trust of your Grandparents? Yes	Do you have the trust of your Grandparents? No	Do you have the trust of your Grandparents? Doesn't Apply
Do you trust your Parents or Primary Care Giver?	Do you trust your Parents or Primary Care Giver? Yes	Do you trust your Parents or Primary Care Giver? No	Do you trust your Parents or Primary Care Giver? Doesn't Apply
Have you been kicked out of your parent's house?	Have you been kicked out of your parent's house? Yes	Have you been kicked out of your parent's house? No	Have you been kicked out of your parent's house? Doesn't Apply
Have you ever embarassed yourself when high?	Have you ever embarassed yourself when high? Yes	Have you ever embarassed yourself when high? No	Have you ever embarassed yourself when high? Doesn't Apply
Have you ever hurt someone you care about as a result of substance use?	Have you ever hurt someone you care about as a result of substance use? Yes	Have you ever hurt someone you care about as a result of substance use? No	Have you ever hurt someone you care about as a result of substance use? Doesn't Apply
Have you gotten into a fight as a result of substance use?	Have you gotten into a fight as a result of substance use? Yes	Have you gotten into a fight as a result of substance use? No	Have you gotten into a fight as a result of substance use? Doesn't Apply
Have you recently lost a good relationship?	Have you recently lost a good relationship? Yes	Have you recently lost a good relationship? No	Have you recently lost a good relationship? Doesn't Apply
Is someone out to get you as a result of substance use?	Is someone out to get you as a result of substance use? Yes	Is someone out to get you as a result of substance use? No	Is someone out to get you as a result of substance use? Doesn't Apply

	No	Yes	Doesn't Apply
Do you have a regular job?	*DO YOU BELONG TO A COMMUNITY? Do you have a regular job? No	Do you have a regular job? Yes	Do you have a regular job? Doesn't Apply
Do you have a regular source for money?	Do you have a regular source for money? No	Do you have a regular source for money? Yes	Do you have a regular source for money? Doesn't Apply
Do you belong to any teams?	Do you belong to any teams? No	Do you belong to any teams? Yes	Do you belong to any teams? Doesn't Apply
Do you participate in a clubs?	Do you participate in a clubs? No	Do you participate in a clubs? Yes	Do you participate in a clubs? Doesn't Apply
Do you attend school everyday?	Do you attend school everyday? No	Do you attend school everyday? Yes	Do you attend school everyday? Doesn't Apply
Do you go to every class everyday?	Do you go to every class everyday? No	Do you go to every class everyday? Yes	Do you go to every class everyday? Doesn't Apply
Do you stop people from bullying others?	Do you stop people from bullying others? No	Do you stop people from bullying others? Yes	Do you stop people from bullying others? Doesn't Apply
Would you report or fill in an anti-harassment complaint form?	Would you report or fill in an anti-harassment complaint form? No	Would you report or fill in an anti-harassment complaint form? Yes	Would you report or fill in an anti-harassment complaint form? Doesn't Apply
Would you report a Teacher conflict to your parents or a school administrator?	Would you report a Teacher conflict to your parents or a school administrator? No	Would you report a Teacher conflict to your parents or a school administrator? Yes	Would you report a Teacher conflict to your parents or a school administrator? Doesn't Apply
Do you resolve conflicts with your school Administrators?	Do you resolve conflicts with your school Administrators? No	Do you resolve conflicts with your school Administrators? Yes	Do you resolve conflicts with your school Administrators? Doesn't Apply
Do you believe all laws should be respected?	Do you believe all laws should be respected? No	Do you believe all laws should be respected? Yes	Do you believe all laws should be respected? Doesn't Apply
Have you gone to a school dance impaired?	Have you gone to a school dance impaired? No	Have you gone to a school dance impaired? Yes	Have you gone to a school dance impaired? Doesn't Apply
Do you worry about not completing school work?	Do you worry about not completing school work? No	Do you worry about not completing school work? Yes	Do you worry about not completing school work? Doesn't Apply
Do you regularly eat lunch with friends?	Do you regularly eat lunch with friends? No	Do you regularly eat lunch with friends? Yes	Do you regularly eat lunch with friends? Doesn't Apply
Are you keeping passing grades?	Are you keeping passing grades? No	Are you keeping passing grades? Yes	Are you keeping passing grades? Doesn't Apply

Follow-up survey for 0708 PRDT Student

Project Resiliency Day Treatment Program Student Intake Questions

*YOUR KEY CONTACT INFORMATION:

*HOW IS YOUR HEALTH AND LIVING CONDITIONS?

*HOW ARE YOUR RELATIONSHIPS?

*DO YOU BELONG TO A COMMUNITY?

*WHAT'S IMPACTING YOUR LIFE?

*Why were you originally referred to Project Resiliency?

*If you chose drugs or alcohol for the question above, have you