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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. My grade:

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* 4. Email address to send you a post-evaluation (data kept confidential -- If under age 13, DO NOT provide ememail address):

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* 5. My definition of respect is:

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* 6. I respect myself by:

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* 7. 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 want to learn new, positive ways to take care of myself.
I want to have a space 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’m comfortable setting boundaries to protect my body, feelings or energy.
I do things each day to manage my stress and energy well.
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.
I sometimes get my friends or people around me to do things that get us in trouble.

T