Skip to content
S.T.U.C.K.'s Questionnaire
1.
How old are you?
12-16
17-21
22-26
27-32
33-39
40+
50+
2.
Do you love yourself?
Yes
No
3.
Can you comfortable look yourself in the mirror?
Yes
No
4.
Are you satisfied with yourself?
Yes
No
5.
Do you have to look or dress a certain way to be accepted?
Yes
No
6.
Are you where you want to be in life?
Yes
No
7.
What do you feel is holding you back?
Lack of resources
Finances
CORI
Partner
Lack of support
Self-Esteem
Children
Disability
8.
Do you feel like it's too late to make a change in your life?
Yes
No
9.
What challenges are you facing?
Lack of resources
Financial support
Legal support
Community Support
Housing
Children
Safety
Other (please specify)
10.
Name one thing you love about yourself?
11.
Name one thing you dislike about yourself?
12.
Are you being abused in any way?
Yes
No
Physically
Verbally
Sexually
Financially
Mentally
Previously
13.
Have you ever thought about or attempted suicide?
Yes
No
14.
Have you ever been to counseling?
Yes
No
15.
Dou you journal?
Yes
No
Sometimes
16.
Do you exercise/workout?
Yes
No
17.
Do you believe in God? (higher Power)
Yes
No
18.
Do you pray or attend church?
Yes
No
Sometimes
19.
Do you have a primary care physician?
Yes
No
20.
Have you had a physical/dental cleaning within the last year?
Yes
No
21.
Do you smoke?
Yes
No
Cigarettes
Marijuana
Both
Other
22.
Do you drink alcohol?
Yes
No
Sometimes
23.
Do you use drugs that are not prescribed to you?
Yes
No
Sometimes
24.
Do you think you have a drug or alcohol dependency?
Yes
No
25.
Are you sexually active?
Yes
No
26.
Are you a virgin?
Yes
No
27.
Do you practice safe sex?
Yes
No
28.
How old were you when you first had sex?
9-12
13-16
17-21+
Younger than 9
Older than 21
29.
How soon after you meet a person do/can they expect sex?
Days
Weeks
Months
30.
How long do you wait before having sex with someone?
Days
Weeks
Months
31.
Have you ever had a STD?
Yes
No
32.
Can you discuss STDs/HIV with your partner?
Yes
No
33.
Have you ever had sex for money or drugs?
Yes
No
34.
Do you believe alcohol/drugs impairs your ability to practice safe sex?
Yes
No
35.
If you wanted to stop using drugs or alcohol could you do so?
Yes
No
36.
Have you ever been arrested while using drugs/alcohol?
Yes
No
37.
At what age did you have your first drink or try drugs?
9-12
13-16
17-21+
Before 9
Over 21
38.
Where did you get it?
Parent
Friend
Partner
Family
Other (please specify)
39.
Do you hide using from others?
Yes
No
Family
Partner
Work
DCF
Courts
40.
Do you need help managing your alcohol or drug use?
Yes
No
41.
Do you have children?
Yes
No
1
2
3+
42.
At what age should you discuss sex, drugs, or alcohol with your children?
4-8
9-12
13-16
43.
Do you have siblings?
Yes
No
1
2
3+
44.
Did you parents discuss the effects of sex, drugs, alcohol with you?
Yes
No
45.
What is your relationship status?
Single
Married
Serious relationship
Dating
Divorced
Separated
46.
Have you ever been physically or sexually assaulted?
Yes
No
47.
Did you report the assault? If so to whom..
Yes
No
Police
Family
Peer/Friend
Too afraid
Partner
48.
Do you have a support team/system?
Yes
No
49.
Have you ever stayed in an unhealthy relationship?
Yes
No
50.
Have you ever abused/caused harm to your partner?
Yes
No
51.
Did you witness violence in your home as a child?
Yes
No
52.
Did you witness drug activity or alcohol abuse in your home as a child?
Yes
No
53.
Who raised you?/Who did you grow up living with?
Parent/s
Grandparent/s
Other Family Members
DSS/DCF
Friends
Other (please specify)
54.
Who did you go to for advice?
Parent/s
Peers
Counselor
Family members
Other (please specify)
55.
How were you disciplined as a child?
I was not disciplined
Yelled at
Punishment
Spankings/Hit
Court involvement
56.
Did you feel loved growing up?
Yes
No
Sometimes
57.
How was love shown/displayed?
Physically- hugs/kisses
Verbally- I love you/you make me proud
Financially- buying lots of things
Lack of discipline- overlooking negative behavior
Protection- knowing you're not alone in tough situations
Love was not shown/displayed
Other (please specify)
58.
Are you in a gang or affiliated?
Yes
No
I was In the past
I know or associate with members but I'm not in a gang
59.
Have you ever been arrested?
Yes
No
60.
Are you on probation or parole?
Yes
No
61.
Has probation/parole been helpful for you in any way?
Yes
No
Somewhat
I have never been on parole/probation
62.
What is the most time that you have spent in jail?
Hours
Days
3-6 months
6-12 months
18-24 months
2+ years
4+ years
more than 6 years
Never been
63.
In jail did you complete any trainings or programs that were beneficial?
Yes
No
Never been
64.
Would you consider yourself a role model?
Yes
No
65.
Was education a priority/requirement in your home?
Yes
No
66.
Do you enjoy reading?
Yes
No
Books
Blogs
Magazines
Newspapers
67.
Did you graduate high school or obtain a GED?
Yes
No
68.
Did your parent/s graduate high school?
Yes
No
69.
Have you been to college?
Yes
No
70.
Did your parent/s attend college?
Yes
No
71.
Has anyone in your household graduated college?
Yes
No
72.
Do you have or want a job?
I have a job
I want a job
I do not have a job
I do not want a job
I need help finding a job
I can not work
73.
What is your source of income?
Employed
Partner
Family
SSI/DTA
Hustle
I do not have an income
74.
How old were you when you started working?
13-16
17-21
21+
I've never had a job
75.
What's the longest period of time you worked at one job?
1-30 days
30-90 days
6-12 months
1-2 years
over two years
I've never had a job
76.
Are you treated fairly at work?
Yes
No
77.
What is preventing you from obtaining employment?
Disability
CORI
Housing
Education
Training Opportunities
Appearance/Clothes
No one will hire me
I do not want a job
I am employed
78.
Do you believe you have to cheat the system to get ahead?
Yes
No
79.
Do you know someone who is more successful hustling than working?
Yes
No
80.
Do you work hard but do not see much progress?
Yes
No
81.
What is your current living situation?
Rent
Own your home
Parent/s
Shelter
Friend/Partner
Family
Homeless
82.
Do you feel safe in your community/Environment?
Yes
No
83.
Would you help someone being physically assaulted?
Yes
No
84.
How would you help?
Speak Up
Physically intervene
Call cops
Record
Witness
Nothing
85.
Do you feel like you need a relationship/partner to be supported or protected?
Yes
No
Previously
86.
Do you need to carry a weapon to feel safe?
Yes
No
Previously
Depends on Community/Environment
87.
Have you ever been shot, stabbed, or robbed?
Yes
No
88.
Do you trust law enforcement in your community?
Yes
No
89.
Have you ever experienced or witnessed police brutality?
Yes I have experienced police burtality
Yes I have witnessed police brutality
Never experienced
Never witnessed
90.
Have you ever been charged with a crime that you did not commit?
Yes
No
91.
Have you been harassed/mistreated by the police in your community?
Yes
No
92.
Who or where do you go for support in your community?
Community Organization
Community Advocate
Community Church
Community Clinic
Community Resource Center/Website
I do not have community support
I do not know what support is available in my community
I do not need support
93.
Have you been prejudged or criticized by DTA, DCF, Housing Workers, or Medical Staff?
Yes
No
94.
Are you a registered voter? Do you Vote?
Yes
No
I'm registered but do not vote
95.
Do you believe your vote makes a difference?
Yes
No
96.
Do you participate in community events?
Yes
No
97.
Are children safe in your community?
Yes
No
98.
Are there safe parks and recreational centers in your community?
Yes
No
99.
Have you ever traveled outside of your state?
Yes
No
100.
Would you like to relocate?
Yes
No
Current Progress,
0 of 100 answered