Screen Reader Mode Icon
EXIT

Question Title

* 1. How old are you?

Question Title

* 2. Do you love yourself?

Question Title

* 3. Can you comfortable look yourself in the mirror?

Question Title

* 4. Are you satisfied with yourself?

Question Title

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

Question Title

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

Question Title

* 7. What do you feel is holding you back?

Question Title

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

Question Title

* 9. What challenges are you facing?

Question Title

* 10. Name one thing you love about yourself?

Question Title

* 11. Name one thing you dislike about yourself?

Question Title

* 12. Are you being abused in any way?

Question Title

* 13. Have you ever thought about or attempted suicide?

Question Title

* 14. Have you ever been to counseling?

Question Title

* 15. Dou you journal?

Question Title

* 16. Do you exercise/workout?

Question Title

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

Question Title

* 18. Do you pray or attend church?

Question Title

* 19. Do you have a primary care physician?

Question Title

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

Question Title

* 21. Do you smoke?

Question Title

* 22. Do you drink alcohol?

Question Title

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

Question Title

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

Question Title

* 25. Are you sexually active?

Question Title

* 26. Are you a virgin?

Question Title

* 27. Do you practice safe sex?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 31. Have you ever had a STD?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 38. Where did you get it?

Question Title

* 39. Do you hide using from others?

Question Title

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

Question Title

* 41. Do you have children?

Question Title

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

Question Title

* 43. Do you have siblings?

Question Title

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

Question Title

* 45. What is your relationship status?

Question Title

* 46. Have you ever been physically or sexually assaulted?

Question Title

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

Question Title

* 48. Do you have a support team/system?

Question Title

* 49. Have you ever stayed in an unhealthy relationship?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 54. Who did you go to for advice?

Question Title

* 55. How were you disciplined as a child?

Question Title

* 56. Did you feel loved growing up?

Question Title

* 57. How was love shown/displayed?

Question Title

* 58. Are you in a gang or affiliated?

Question Title

* 59. Have you ever been arrested?

Question Title

* 60. Are you on probation or parole?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 64. Would you consider yourself a role model?

Question Title

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

Question Title

* 66. Do you enjoy reading?

Question Title

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

Question Title

* 68. Did your parent/s graduate high school?

Question Title

* 69. Have you been to college?

Question Title

* 70. Did your parent/s attend college?

Question Title

* 71. Has anyone in your household graduated college?

Question Title

* 72. Do you have or want a job?

Question Title

* 73. What is your source of income?

Question Title

* 74. How old were you when you started working?

Question Title

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

Question Title

* 76. Are you treated fairly at work?

Question Title

* 77. What is preventing you from obtaining employment?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 81. What is your current living situation?

Question Title

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

Question Title

* 83. Would you help someone being physically assaulted?

Question Title

* 84. How would you help?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 88. Do you trust law enforcement in your community?

Question Title

* 89. Have you ever experienced or witnessed police brutality?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 95. Do you believe your vote makes a difference?

Question Title

* 96. Do you participate in community events?

Question Title

* 97. Are children safe in your community?

Question Title

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

Question Title

* 99. Have you ever traveled outside of your state?

Question Title

* 100. Would you like to relocate?

0 of 100 answered
 

T