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1. How old are you?

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2. Do you love yourself?

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3. Can you comfortable look yourself in the mirror?

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4. Are you satisfied with yourself?

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5. Do you have to look or dress a certain way to be accepted?

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6. Are you where you want to be in life?

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7. What do you feel is holding you back?

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8. Do you feel like it's too late to make a change in your life?

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9. What challenges are you facing?

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10. Name one thing you love about yourself?

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11. Name one thing you dislike about yourself?

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12. Are you being abused in any way?

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13. Have you ever thought about or attempted suicide?

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14. Have you ever been to counseling?

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15. Dou you journal?

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16. Do you exercise/workout?

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17. Do you believe in God? (higher Power)

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18. Do you pray or attend church?

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19. Do you have a primary care physician?

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20. Have you had a physical/dental cleaning within the last year?

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21. Do you smoke?

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22. Do you drink alcohol?

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23. Do you use drugs that are not prescribed to you?

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24. Do you think you have a drug or alcohol dependency? 

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25. Are you sexually active?

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26. Are you a virgin?

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27. Do you practice safe sex?

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28. How old were you when you first had sex?

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29. How soon after you meet a person do/can they expect sex?

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30. How long do you wait before having sex with someone?

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31. Have you ever had a STD?

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32. Can you discuss STDs/HIV with your partner?

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33. Have you ever had sex for money or drugs?

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34. Do you believe alcohol/drugs impairs your ability to practice safe sex?

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35. If you wanted to stop using drugs or alcohol could you do so?

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36. Have you ever been arrested while using drugs/alcohol?

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37. At what age did you have your first drink or try drugs?

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38. Where did you get it?

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39. Do you hide using from others?

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40. Do you need help managing your alcohol or drug use?

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41. Do you have children?

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42. At what age should you discuss sex, drugs, or alcohol with your children?

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43. Do you have siblings?

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44. Did you parents discuss the effects of sex, drugs, alcohol with you?

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45. What is your relationship status?

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46. Have you ever been physically or sexually assaulted?

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47. Did you report the assault? If so to whom..

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48. Do you have a support team/system?

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49. Have you ever stayed in an unhealthy relationship?

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50. Have you ever abused/caused harm to your partner?

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51. Did you witness violence in your home as a child?

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52. Did you witness drug activity or alcohol abuse in your home as a child?

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53. Who raised you?/Who did you grow up living with?

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54. Who did you go to for advice?

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55. How were you disciplined as a child?

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56. Did you feel loved growing up?

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57. How was love shown/displayed?

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58. Are you in a gang or affiliated?

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59. Have you ever been arrested?

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60. Are you on probation or parole?

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61. Has probation/parole been helpful for you in any way?

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62. What is the most time that you have spent in jail?

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63. In jail did you complete any trainings or programs that were beneficial?

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64. Would you consider yourself a role model?

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65. Was education a priority/requirement in your home?

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66. Do you enjoy reading?

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67. Did you graduate high school or obtain a GED?

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68. Did your parent/s graduate high school?

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69. Have you been to college?

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70. Did your parent/s attend college?

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71. Has anyone in your household graduated college?

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72. Do you have or want a job?

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73. What is your source of income?

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74. How old were you when you started working?

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75. What's the longest period of time you worked at one job?

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76. Are you treated fairly at work?

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77. What is preventing you from obtaining employment?

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78. Do you believe you have to cheat the system to get ahead?

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79. Do you know someone who is more successful hustling than working?

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80. Do you work hard but do not see much progress?

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81. What is your current living situation?

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82. Do you feel safe in your community/Environment?

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83. Would you help someone being physically assaulted?

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84. How would you help?

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85. Do you feel like you need a relationship/partner to be supported or protected?

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86. Do you need to carry a weapon to feel safe?

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87. Have you ever been shot, stabbed, or robbed? 

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88. Do you trust law enforcement in your community?

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89. Have you ever experienced or witnessed police brutality?

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90. Have you ever been charged with a crime that you did not commit?

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91. Have you been harassed/mistreated by the police in your community?

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92. Who or where do you go for support in your community?

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93. Have you been prejudged or criticized by DTA, DCF, Housing Workers, or Medical Staff?

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94. Are you a registered voter? Do you Vote?

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95. Do you believe your vote makes a difference?

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96. Do you participate in community events?

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97. Are children safe in your community?

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98. Are there safe parks and recreational centers in your community?

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99. Have you ever traveled outside of your state?

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100. Would you like to relocate?

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