Natural Helpers Survey
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1. Default Section
1
. I am:
I am:
female
male
2
. What grade are you in?
What grade are you in?
9
10
11
12
3
. When I have a problem, I usually try to get help from:
When I have a problem, I usually try to get help from:
a friend
a parent
an adult at school (counselor, teacher, coach)
an adult outside of school (pastor, youthworker, neighbor or relative
a brother or sister
4
. Please list the names of two adults you trust and feel comfortable talking to about a personal problem:
Please list the names of two adults you trust and feel comfortable talking to about a personal problem:
Adult 1
Adult 2
5
. Please list the names of two adults at this school that you trust and feel comfortable talking to about a personal problem:
Please list the names of two adults at this school that you trust and feel comfortable talking to about a personal problem:
School Adult 1
School Adult 2
6
. Please list the names of two students that you trust and feel comfortable talk to about a personal problem:
Please list the names of two students that you trust and feel comfortable talk to about a personal problem:
Student 1
Student 2
7
. Read all of the concerns listed below and then select the top five concerns that you believe are major issues for you and for your friends.
*Adults: select the top five concerns that you believe are major issues for the students in our school.
Read all of the concerns listed below and then select the top five concerns that you believe are major issues for you and for your friends. *Adults: select the top five concerns that you believe are major issues for the students in our school.
Abuse (sexual, physical, emotional or threats of abuse)
Achievement at school (grades and goals)
Alcohol use
Career or college choices
depression
dropping out or being suspended/disciplined
drug use (marijuana, cocaine, meth, nicotine etc)
Eating disorders
Family (communication, relationships, conflicts with family members)
Friendships (jealousy, communication, support)
Gossip/Rumors
Loneliness
Loss (separation, divorce, death)
Money
Peer pressure
Popularity (fitting in, belonging)
Pregnancy
Romantic relationships (girlfriend/boyfriend)
Self Image
Sex-related concerns (sexual/romantic behavior, sexual identity, sexual limits, birth control)
Sexually transmitted diseases
Stress (not enough time, other pressure)
Thoughts of suicide
Self destructive actions/high risk behavior (cutting, burning, driving like you don't care if you have an accident)
War/terrorism
World issues (hunger, poverty, environment)
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