CC & PW Start Up Survey

Please answer the following questions to help us keep statistics for our program.
Note: All answers are confidential.

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* 1. Age

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* 2. Sleep at Night ( 1=Poor - 5=Excellent)

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* 3. Focus during the day ( 1=Poor - 5=Excellent)

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* 4. Fitness levels ( 1=Poor - 5=Excellent)

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* 5. Overall Energy ( 1=Poor - 5=Excellent)

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* 6. Social Life ( 1=Poor - 5=Excellent)

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* 7. Clarity of thought

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* 8. Lately i have been angry

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* 9. I feel tired all the time

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* 10. Right now i am very happy

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* 11. I Always doubt myself

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* 12. Have you ever used drugs?

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* 13. If you have used drugs, when was the last time?

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* 14. What drugs have you tried?

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* 15. Has someone close to you been effected by drugs?

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* 16. If you have not tried drugs, Why haven't you?

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* 17. How well educated about ICE are you?

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* 18. Have you ever been intoxicated?

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* 19. If you have been intoxicated, when was the last time?

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* 20. When you drink, What is your main reason?

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* 21. How well educated are you about alcohol?

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* 22. Have you ever worked with a Psychologist?

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* 23. Have you ever been diagnosed with a Mental Health Challenge?

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* 24. If Yes, What was it?

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* 25. Has someone close to you been affected by a Mental Health Challenge?

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* 26. Have you ever had self harming thoughts?

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* 27. If you have had self harming thoughts, When was the last time you had them?

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* 28. How well do you understand Depression?

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* 29. How often would you gamble on sport?

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* 30. Have you ever been a victim of domestic violence?

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