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* 1. Organization (Name of org that provided this survey to you):

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* 2. My age:

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* 3. Right now, my definition of respect is:

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* 4. Right now, I respect myself by:

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* 5. Please select the choice that best describes how you feel about each of the following statements right now.

  Strongly Agree Agree Disagree Strongly Disagree
I have adults in my life I trust.
I feel safe to speak my truth.
I have peers that I trust and that listen to me.
It’s sometimes hard for me to listen to others without wanting to interrupt.
I have adults in my life that take care of me and help me.
I know positive ways to take care of myself.
I have a place to share challenges in my life and find ways to move forward positively.
I am willing to take chances even if I know I could fail.
I feel weak or embarrassed when I ask for help.
I understand there are rules at school and home and someone expects me to follow them.
I’m comfortable setting boundaries to protect my body, feelings or energy.
I believe that life is what you make it.
I set boundaries with others to make sure I reach my life and academic goals.
I feel I am an important person who can positively impact our world.
Adults in my life notice what I am capable of and that I have potential.

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