Skip to content
YOUTH EVALUATION - NH 5
YOUTH EVALUATION
ALL INFO WILL BE KEPT CONFIDENTIAL - SO PLEASE FEEL FREE TO ANSWER THE QUESTIONS OPENLY, AND HONESTLY.
I am in:
N/A
4th Grade or below
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College
Which Natural High film did you watch?
Natural High 1
Natural High 2
Natural High 3
Natural High 4
Natural High 5
Do you know what your natural high is?
YES
NO
If so, what is it and how does it make you feel?
Do you know where you can go to pursue or get more information regarding your natural high?
YES
NO
On a scale of 1 to 10, how much has the film encouraged you to reject drugs and alcohol? 1 meaning it did not encourage me at all, and 10 meaning it encouraged me a lot - I will not do them!
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10, how much has the film encouraged you to find a Natural High? 1 meaning it did not encourage me at all, and 10 meaning it encouraged me a lot!
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Do you believe having a natural high will help fight the temptation to turn to drugs and alcohol?
Answer option:
YES
MAYBE
DON'T KNOW
NO
After participating in the Natural High program, have you made a choice to live drug-free and naturally high?
YES
NO
After watching Natural High and participating in the program, do you agree that you will tell your friends about living naturally high?
Agree a lot
Agree a little
Disagree a little
Disagree a lot
Don’t know
If you were designing Natural High 6 how important would the following be if they were included? Use a 1 - 10 scale (10 being very important):
1
2
3
4
5
6
7
8
9
10
Stories from drug-free celebrities that I look up to
1
2
3
4
5
6
7
8
9
10
Stories about drug-free youth that look like me
1
2
3
4
5
6
7
8
9
10
Ways I can stay naturally high
1
2
3
4
5
6
7
8
9
10
How to find out what your natural high is
1
2
3
4
5
6
7
8
9
10
A story about losing someone to drugs, like Jon Sundt's story
1
2
3
4
5
6
7
8
9
10
A recovery story EX: someone who is recovering from drugs
1
2
3
4
5
6
7
8
9
10
Please tell us your ideas about what you would like to see included in Natural High 6:
If you could tell anyone at Natural High anything about the DVD or your program participation, what would it be?
Contact Info:
First Name:
Last Initial:
State/Province:
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
Date of Birth (08-04-1988)
School and Teacher Information
Teacher Name:
School Name:
ZIP/Postal Code: