1. Influences Survey
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When I think of what makes me choose and do the things I do, when I think of how I view myself and reflect about my core values and my view of life and the world, I have to wonder about what influences me. Please take this survey with great care and thoughtfulness. Thank you for your time and sharing your opinions. We’re doing this for yours and our discussion and understanding.
1
. Gender:
Gender:
Male
Female
2
. What grade are you in?
Choose not to answer
Not in school
7th
8
9
10
11
12
College
Grad School
What grade are you in?
3
. How old are you?
How old are you?
4
. What most influences you? (Choose the top 3 things that influence you the most).
What most influences you? (Choose the top 3 things that influence you the most).
Mother (biological or step, whoever is the most important)
Father (biological or step)
Siblings (brothers or sisters, biological or step)
Grandparents
Other relatives (aunts, uncles, cousins, etc.)
Closest friends (those closest to you and with whom you spend the most time or communicate with the most)
Other peers (classmates, teammates, etc.)
Celebrities (popularized performers and entertainers from any field)
Neighborhood (your community, your immediate neighborhood, streets, park, etc.)
Schools and teachers
Sports and coaches
Music
Job, coworkers and bosses
Doctors, medical workers, counselors
Religious faith (Church, Mosque, or Synagogue, youth group, camps, etc.)
Advertisements (commercial in any form, on screens, billboards, in magazines, etc., all around us everywhere)
Media (movies, TV, radio, magazines, internet, etc.)
Books
Video games
Pornography
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