Lena Mae Moses Middle School Peer Leader Pre-Survey

The following survey asks personal but important questions about your attitudes and behaviors regarding suicide, substance use, and seeking help from other teens and adults. The purpose of this survey is to understand how well the Sources of Strength program helps you and other students at your school connect with adults to talk about problems you may have.

Completing this survey is voluntary, and all responses will be kept anonymous. Your name will not be connected in any way to your answers. Please answer the questions based on what you really think or do. If you are not comfortable answering a question, just leave it blank.

If you experience discomfort or distress while taking this survey, please stop and close the survey. Please also reach out to Mary Wade at mwade@paulding.k12.ga.us AND a trusted adult in your home about any distress that you are experiencing.

You may also call the Georgia Crisis and Access Line at 1-800-715-4225 or text SCHOOL to 741741 free 24/7 crisis counseling.

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* 1. How are you attending school this year?

In-Person instruction only

Virtual instruction only

A blend of virtual and in-person instruction

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* 2. Peer Leader ID Number

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* 3. What is your age?

10 years or younger

19 or older

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* 4. What is your gender?

Female

Male

Other

Other gender, please specify

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* 5. What race or ethncity do you most identify with?

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

Multiracial (more than one race)

Native Hawaiian or Other Pacific Islander

White or Caucasian

Other (please specify)

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* 6. What is your grade?

6th

7th

8th

9th

10th

11th

12th

How strongly do you disagree or agree with the following statements?

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* 7. At my school...

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a) ...there is an adult who I trust	a) ...there is an adult who I trust Strongly Disagree	a) ...there is an adult who I trust Disagree	a) ...there is an adult who I trust Neither Agree nor Disagree	a) ...there is an adult who I trust Agree	a) ...there is an adult who I trust Strongly Agree
b) ...there is an adult who cares about me	b) ...there is an adult who cares about me Strongly Disagree	b) ...there is an adult who cares about me Disagree	b) ...there is an adult who cares about me Neither Agree nor Disagree	b) ...there is an adult who cares about me Agree	b) ...there is an adult who cares about me Strongly Agree
c) ...there is an adult I can talk to about a problem	c) ...there is an adult I can talk to about a problem Strongly Disagree	c) ...there is an adult I can talk to about a problem Disagree	c) ...there is an adult I can talk to about a problem Neither Agree nor Disagree	c) ...there is an adult I can talk to about a problem Agree	c) ...there is an adult I can talk to about a problem Strongly Agree

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* 8. If I was upset and needed help...

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a) ...I believe a counselor or other adult at school could help me IF THEY KNEW	a) ...I believe a counselor or other adult at school could help me IF THEY KNEW Strongly Disagree	a) ...I believe a counselor or other adult at school could help me IF THEY KNEW Disagree	a) ...I believe a counselor or other adult at school could help me IF THEY KNEW Neither Agree nor Disagree	a) ...I believe a counselor or other adult at school could help me IF THEY KNEW Agree	a) ...I believe a counselor or other adult at school could help me IF THEY KNEW Strongly Agree
b) ...I would talk to a counselor or other adult at school	b) ...I would talk to a counselor or other adult at school Strongly Disagree	b) ...I would talk to a counselor or other adult at school Disagree	b) ...I would talk to a counselor or other adult at school Neither Agree nor Disagree	b) ...I would talk to a counselor or other adult at school Agree	b) ...I would talk to a counselor or other adult at school Strongly Agree
c) ...my friends would want me to talk to a counselor or other adult at school	c) ...my friends would want me to talk to a counselor or other adult at school Strongly Disagree	c) ...my friends would want me to talk to a counselor or other adult at school Disagree	c) ...my friends would want me to talk to a counselor or other adult at school Neither Agree nor Disagree	c) ...my friends would want me to talk to a counselor or other adult at school Agree	c) ...my friends would want me to talk to a counselor or other adult at school Strongly Agree
d) ...my family would want me to talk to a counselor or other adult at school	d) ...my family would want me to talk to a counselor or other adult at school Strongly Disagree	d) ...my family would want me to talk to a counselor or other adult at school Disagree	d) ...my family would want me to talk to a counselor or other adult at school Neither Agree nor Disagree	d) ...my family would want me to talk to a counselor or other adult at school Agree	d) ...my family would want me to talk to a counselor or other adult at school Strongly Agree

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* 9. In my opinion...

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a) ...a suicidal teen should be left alone if he/she doesn’t want help	a) ...a suicidal teen should be left alone if he/she doesn’t want help Strongly Disagree	a) ...a suicidal teen should be left alone if he/she doesn’t want help Disagree	a) ...a suicidal teen should be left alone if he/she doesn’t want help Neither Agree nor Disagree	a) ...a suicidal teen should be left alone if he/she doesn’t want help Agree	a) ...a suicidal teen should be left alone if he/she doesn’t want help Strongly Agree
b) ...I would tell an adult I trusted if I knew a friend was suicidal	b) ...I would tell an adult I trusted if I knew a friend was suicidal Strongly Disagree	b) ...I would tell an adult I trusted if I knew a friend was suicidal Disagree	b) ...I would tell an adult I trusted if I knew a friend was suicidal Neither Agree nor Disagree	b) ...I would tell an adult I trusted if I knew a friend was suicidal Agree	b) ...I would tell an adult I trusted if I knew a friend was suicidal Strongly Agree
c) ...I would tell an adult about a suicidal friend, even if that friend asked me to keep it a secret	c) ...I would tell an adult about a suicidal friend, even if that friend asked me to keep it a secret Strongly Disagree	c) ...I would tell an adult about a suicidal friend, even if that friend asked me to keep it a secret Disagree	c) ...I would tell an adult about a suicidal friend, even if that friend asked me to keep it a secret Neither Agree nor Disagree	c) ...I would tell an adult about a suicidal friend, even if that friend asked me to keep it a secret Agree	c) ...I would tell an adult about a suicidal friend, even if that friend asked me to keep it a secret Strongly Agree
d) …I would tell an adult about a friend who was using drugs or alcohol	d) …I would tell an adult about a friend who was using drugs or alcohol Strongly Disagree	d) …I would tell an adult about a friend who was using drugs or alcohol Disagree	d) …I would tell an adult about a friend who was using drugs or alcohol Neither Agree nor Disagree	d) …I would tell an adult about a friend who was using drugs or alcohol Agree	d) …I would tell an adult about a friend who was using drugs or alcohol Strongly Agree
e) ...I would tell an adult about a friend who was using drugs or alcohol, even if that friend asked me to keep it a secret	e) ...I would tell an adult about a friend who was using drugs or alcohol, even if that friend asked me to keep it a secret Strongly Disagree	e) ...I would tell an adult about a friend who was using drugs or alcohol, even if that friend asked me to keep it a secret Disagree	e) ...I would tell an adult about a friend who was using drugs or alcohol, even if that friend asked me to keep it a secret Neither Agree nor Disagree	e) ...I would tell an adult about a friend who was using drugs or alcohol, even if that friend asked me to keep it a secret Agree	e) ...I would tell an adult about a friend who was using drugs or alcohol, even if that friend asked me to keep it a secret Strongly Agree
f) ...my friends would try to get help for someone who was suicidal	f) ...my friends would try to get help for someone who was suicidal Strongly Disagree	f) ...my friends would try to get help for someone who was suicidal Disagree	f) ...my friends would try to get help for someone who was suicidal Neither Agree nor Disagree	f) ...my friends would try to get help for someone who was suicidal Agree	f) ...my friends would try to get help for someone who was suicidal Strongly Agree
g) ...I know adults who could help a friend thinking of suicide	g) ...I know adults who could help a friend thinking of suicide Strongly Disagree	g) ...I know adults who could help a friend thinking of suicide Disagree	g) ...I know adults who could help a friend thinking of suicide Neither Agree nor Disagree	g) ...I know adults who could help a friend thinking of suicide Agree	g) ...I know adults who could help a friend thinking of suicide Strongly Agree
h) ...students with problems can get help from adults in my school	h) ...students with problems can get help from adults in my school Strongly Disagree	h) ...students with problems can get help from adults in my school Disagree	h) ...students with problems can get help from adults in my school Neither Agree nor Disagree	h) ...students with problems can get help from adults in my school Agree	h) ...students with problems can get help from adults in my school Strongly Agree
i) …using drugs or alcohol can help students feel less depressed	i) …using drugs or alcohol can help students feel less depressed Strongly Disagree	i) …using drugs or alcohol can help students feel less depressed Disagree	i) …using drugs or alcohol can help students feel less depressed Neither Agree nor Disagree	i) …using drugs or alcohol can help students feel less depressed Agree	i) …using drugs or alcohol can help students feel less depressed Strongly Agree

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* 10. During the past 12 months, how many times have you:

	0	1	2	3-4	5-6	7 or more
a) …told a friend who was upset, stressed or angry to get help from an adult?	a) …told a friend who was upset, stressed or angry to get help from an adult? 0	a) …told a friend who was upset, stressed or angry to get help from an adult? 1	a) …told a friend who was upset, stressed or angry to get help from an adult? 2	a) …told a friend who was upset, stressed or angry to get help from an adult? 3-4	a) …told a friend who was upset, stressed or angry to get help from an adult? 5-6	a) …told a friend who was upset, stressed or angry to get help from an adult? 7 or more
b) …gone to an adult to get help for a friend who was upset, stressed or angry?	b) …gone to an adult to get help for a friend who was upset, stressed or angry? 0	b) …gone to an adult to get help for a friend who was upset, stressed or angry? 1	b) …gone to an adult to get help for a friend who was upset, stressed or angry? 2	b) …gone to an adult to get help for a friend who was upset, stressed or angry? 3-4	b) …gone to an adult to get help for a friend who was upset, stressed or angry? 5-6	b) …gone to an adult to get help for a friend who was upset, stressed or angry? 7 or more
c) …told a friend who was suicidal to get help from an adult?	c) …told a friend who was suicidal to get help from an adult? 0	c) …told a friend who was suicidal to get help from an adult? 1	c) …told a friend who was suicidal to get help from an adult? 2	c) …told a friend who was suicidal to get help from an adult? 3-4	c) …told a friend who was suicidal to get help from an adult? 5-6	c) …told a friend who was suicidal to get help from an adult? 7 or more
d) …gone to an adult to get help for a suicidal friend?	d) …gone to an adult to get help for a suicidal friend? 0	d) …gone to an adult to get help for a suicidal friend? 1	d) …gone to an adult to get help for a suicidal friend? 2	d) …gone to an adult to get help for a suicidal friend? 3-4	d) …gone to an adult to get help for a suicidal friend? 5-6	d) …gone to an adult to get help for a suicidal friend? 7 or more
e) …told a friend who was using drugs or alcohol to get help from an adult?	e) …told a friend who was using drugs or alcohol to get help from an adult? 0	e) …told a friend who was using drugs or alcohol to get help from an adult? 1	e) …told a friend who was using drugs or alcohol to get help from an adult? 2	e) …told a friend who was using drugs or alcohol to get help from an adult? 3-4	e) …told a friend who was using drugs or alcohol to get help from an adult? 5-6	e) …told a friend who was using drugs or alcohol to get help from an adult? 7 or more
f) …gone to an adult to get help for a friend who was using drugs or alcohol?	f) …gone to an adult to get help for a friend who was using drugs or alcohol? 0	f) …gone to an adult to get help for a friend who was using drugs or alcohol? 1	f) …gone to an adult to get help for a friend who was using drugs or alcohol? 2	f) …gone to an adult to get help for a friend who was using drugs or alcohol? 3-4	f) …gone to an adult to get help for a friend who was using drugs or alcohol? 5-6	f) …gone to an adult to get help for a friend who was using drugs or alcohol? 7 or more
g) …gone to an adult for help when you were upset, stressed or angry?	g) …gone to an adult for help when you were upset, stressed or angry? 0	g) …gone to an adult for help when you were upset, stressed or angry? 1	g) …gone to an adult for help when you were upset, stressed or angry? 2	g) …gone to an adult for help when you were upset, stressed or angry? 3-4	g) …gone to an adult for help when you were upset, stressed or angry? 5-6	g) …gone to an adult for help when you were upset, stressed or angry? 7 or more
h) …gone to an adult to talk about your alcohol or drug use?	h) …gone to an adult to talk about your alcohol or drug use? 0	h) …gone to an adult to talk about your alcohol or drug use? 1	h) …gone to an adult to talk about your alcohol or drug use? 2	h) …gone to an adult to talk about your alcohol or drug use? 3-4	h) …gone to an adult to talk about your alcohol or drug use? 5-6	h) …gone to an adult to talk about your alcohol or drug use? 7 or more

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* 11. During the past 12 months...

	No	Yes
a) ...did you ever seriously consider suicide?	a) ...did you ever seriously consider suicide? No	a) ...did you ever seriously consider suicide? Yes
b) ...did you make a plan on how you would attempt suicide?	b) ...did you make a plan on how you would attempt suicide? No	b) ...did you make a plan on how you would attempt suicide? Yes

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* 12. During the past 12 months, how many times did you actually attempt suicide?

6 or more

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* 13. If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?

Yes

Not applicable, I did not attempt suicide in the past 12 months.

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* 14. If you seriously considered suicide in the past 12 months…

	No	Yes	Not applicable, I did not seriously consider suicide in the past 12 months
a) …did you tell a friend or other teen that you were suicidal?	a) …did you tell a friend or other teen that you were suicidal? No	a) …did you tell a friend or other teen that you were suicidal? Yes	a) …did you tell a friend or other teen that you were suicidal? Not applicable, I did not seriously consider suicide in the past 12 months
b) …did you tell an adult that you were suicidal?	b) …did you tell an adult that you were suicidal? No	b) …did you tell an adult that you were suicidal? Yes	b) …did you tell an adult that you were suicidal? Not applicable, I did not seriously consider suicide in the past 12 months

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* 15. In the past 12 months, If you told a friend or other teen that you were suicidal, did the friend or teen you told…

	No	Yes	Not applicable, I did not tell a friend or other teen that I was suicidal in the past 12 months
a) …encourage you to get help from an adult?	a) …encourage you to get help from an adult? No	a) …encourage you to get help from an adult? Yes	a) …encourage you to get help from an adult? Not applicable, I did not tell a friend or other teen that I was suicidal in the past 12 months
b) …get an adult involved to help you?	b) …get an adult involved to help you? No	b) …get an adult involved to help you? Yes	b) …get an adult involved to help you? Not applicable, I did not tell a friend or other teen that I was suicidal in the past 12 months

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* 16. In the past 12 months, if you told an adult you were suicidal, did any of the adults you told…

	No	Yes	Not applicable, I did not tell an adult I was suicidal in the past 12 months.
a) ...take action or give advice that helped you?	a) ...take action or give advice that helped you? No	a) ...take action or give advice that helped you? Yes	a) ...take action or give advice that helped you? Not applicable, I did not tell an adult I was suicidal in the past 12 months.
b) ...encourage you to get help from a counselor or other adult?	b) ...encourage you to get help from a counselor or other adult? No	b) ...encourage you to get help from a counselor or other adult? Yes	b) ...encourage you to get help from a counselor or other adult? Not applicable, I did not tell an adult I was suicidal in the past 12 months.

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* 17. In the past 12 months, If you told a friend, other teen, or adult that you were suicidal, did you get the help you needed?

Yes

Not applicable, I did not tell a friend, teen or adult I was suicidal in the past 12 months.

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* 18. During the past 30 days, on how many days did you…

	0 days	1-5 days	6-10 days	11-20 days	more than 20 days
a) …have at least one drink of alcohol?	a) …have at least one drink of alcohol? 0 days	a) …have at least one drink of alcohol? 1-5 days	a) …have at least one drink of alcohol? 6-10 days	a) …have at least one drink of alcohol? 11-20 days	a) …have at least one drink of alcohol? more than 20 days
b) …drink 5 or more drinks of alcohol in a row, that is, within a couple of hours?	b) …drink 5 or more drinks of alcohol in a row, that is, within a couple of hours? 0 days	b) …drink 5 or more drinks of alcohol in a row, that is, within a couple of hours? 1-5 days	b) …drink 5 or more drinks of alcohol in a row, that is, within a couple of hours? 6-10 days	b) …drink 5 or more drinks of alcohol in a row, that is, within a couple of hours? 11-20 days	b) …drink 5 or more drinks of alcohol in a row, that is, within a couple of hours? more than 20 days
c) …smoke cigarettes?	c) …smoke cigarettes? 0 days	c) …smoke cigarettes? 1-5 days	c) …smoke cigarettes? 6-10 days	c) …smoke cigarettes? 11-20 days	c) …smoke cigarettes? more than 20 days
d) …use any other tobacco products?	d) …use any other tobacco products? 0 days	d) …use any other tobacco products? 1-5 days	d) …use any other tobacco products? 6-10 days	d) …use any other tobacco products? 11-20 days	d) …use any other tobacco products? more than 20 days
e) …vape THC?	e) …vape THC? 0 days	e) …vape THC? 1-5 days	e) …vape THC? 6-10 days	e) …vape THC? 11-20 days	e) …vape THC? more than 20 days
f) …vape nicotine?	f) …vape nicotine? 0 days	f) …vape nicotine? 1-5 days	f) …vape nicotine? 6-10 days	f) …vape nicotine? 11-20 days	f) …vape nicotine? more than 20 days
g) …use marijuana (also called pot, weed) or hashish?	g) …use marijuana (also called pot, weed) or hashish? 0 days	g) …use marijuana (also called pot, weed) or hashish? 1-5 days	g) …use marijuana (also called pot, weed) or hashish? 6-10 days	g) …use marijuana (also called pot, weed) or hashish? 11-20 days	g) …use marijuana (also called pot, weed) or hashish? more than 20 days
h) …use methamphetamines (also called speed, crystal/crystal, meth, crank, or ice)?	h) …use methamphetamines (also called speed, crystal/crystal, meth, crank, or ice)? 0 days	h) …use methamphetamines (also called speed, crystal/crystal, meth, crank, or ice)? 1-5 days	h) …use methamphetamines (also called speed, crystal/crystal, meth, crank, or ice)? 6-10 days	h) …use methamphetamines (also called speed, crystal/crystal, meth, crank, or ice)? 11-20 days	h) …use methamphetamines (also called speed, crystal/crystal, meth, crank, or ice)? more than 20 days
i) ...use heroin (also called dope, crack, smack, junk, or snow)?	i) ...use heroin (also called dope, crack, smack, junk, or snow)? 0 days	i) ...use heroin (also called dope, crack, smack, junk, or snow)? 1-5 days	i) ...use heroin (also called dope, crack, smack, junk, or snow)? 6-10 days	i) ...use heroin (also called dope, crack, smack, junk, or snow)? 11-20 days	i) ...use heroin (also called dope, crack, smack, junk, or snow)? more than 20 days
j) …use a prescription painkiller (such as Hydrocodone/Hydros, Oxycodone/Oxy, Gabapentin/Gabbies or Tramadol/Trammies) that was not prescribed to you?	j) …use a prescription painkiller (such as Hydrocodone/Hydros, Oxycodone/Oxy, Gabapentin/Gabbies or Tramadol/Trammies) that was not prescribed to you? 0 days	j) …use a prescription painkiller (such as Hydrocodone/Hydros, Oxycodone/Oxy, Gabapentin/Gabbies or Tramadol/Trammies) that was not prescribed to you? 1-5 days	j) …use a prescription painkiller (such as Hydrocodone/Hydros, Oxycodone/Oxy, Gabapentin/Gabbies or Tramadol/Trammies) that was not prescribed to you? 6-10 days	j) …use a prescription painkiller (such as Hydrocodone/Hydros, Oxycodone/Oxy, Gabapentin/Gabbies or Tramadol/Trammies) that was not prescribed to you? 11-20 days	j) …use a prescription painkiller (such as Hydrocodone/Hydros, Oxycodone/Oxy, Gabapentin/Gabbies or Tramadol/Trammies) that was not prescribed to you? more than 20 days
k) …use a prescription drug tranquilizer or sedative (such as Benzos, Xanax/Xans, Klonopin, or Ativan) that was not prescribed to you?	k) …use a prescription drug tranquilizer or sedative (such as Benzos, Xanax/Xans, Klonopin, or Ativan) that was not prescribed to you? 0 days	k) …use a prescription drug tranquilizer or sedative (such as Benzos, Xanax/Xans, Klonopin, or Ativan) that was not prescribed to you? 1-5 days	k) …use a prescription drug tranquilizer or sedative (such as Benzos, Xanax/Xans, Klonopin, or Ativan) that was not prescribed to you? 6-10 days	k) …use a prescription drug tranquilizer or sedative (such as Benzos, Xanax/Xans, Klonopin, or Ativan) that was not prescribed to you? 11-20 days	k) …use a prescription drug tranquilizer or sedative (such as Benzos, Xanax/Xans, Klonopin, or Ativan) that was not prescribed to you? more than 20 days
l) …use a prescription drug stimulant (such as Ritalin or Adderall) that was not prescribed to you?	l) …use a prescription drug stimulant (such as Ritalin or Adderall) that was not prescribed to you? 0 days	l) …use a prescription drug stimulant (such as Ritalin or Adderall) that was not prescribed to you? 1-5 days	l) …use a prescription drug stimulant (such as Ritalin or Adderall) that was not prescribed to you? 6-10 days	l) …use a prescription drug stimulant (such as Ritalin or Adderall) that was not prescribed to you? 11-20 days	l) …use a prescription drug stimulant (such as Ritalin or Adderall) that was not prescribed to you? more than 20 days

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* 19. How much, if at all, would you agree or disagree with the following statements?

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a) I feel supported and cared for by my family	a) I feel supported and cared for by my family Strongly Disagree	a) I feel supported and cared for by my family Disagree	a) I feel supported and cared for by my family Neither Agree nor Disagree	a) I feel supported and cared for by my family Agree	a) I feel supported and cared for by my family Strongly Agree
b) I have positive, caring friends	b) I have positive, caring friends Strongly Disagree	b) I have positive, caring friends Disagree	b) I have positive, caring friends Neither Agree nor Disagree	b) I have positive, caring friends Agree	b) I have positive, caring friends Strongly Agree
c) I have friendships with adults that I trust	c) I have friendships with adults that I trust Strongly Disagree	c) I have friendships with adults that I trust Disagree	c) I have friendships with adults that I trust Neither Agree nor Disagree	c) I have friendships with adults that I trust Agree	c) I have friendships with adults that I trust Strongly Agree
d) I think using drugs or alcohol can help me when I’m feeling depressed	d) I think using drugs or alcohol can help me when I’m feeling depressed Strongly Disagree	d) I think using drugs or alcohol can help me when I’m feeling depressed Disagree	d) I think using drugs or alcohol can help me when I’m feeling depressed Neither Agree nor Disagree	d) I think using drugs or alcohol can help me when I’m feeling depressed Agree	d) I think using drugs or alcohol can help me when I’m feeling depressed Strongly Agree
e) I am active in healthy activities, hobbies, etc.	e) I am active in healthy activities, hobbies, etc. Strongly Disagree	e) I am active in healthy activities, hobbies, etc. Disagree	e) I am active in healthy activities, hobbies, etc. Neither Agree nor Disagree	e) I am active in healthy activities, hobbies, etc. Agree	e) I am active in healthy activities, hobbies, etc. Strongly Agree
f) I take time to be generous and helpful to others	f) I take time to be generous and helpful to others Strongly Disagree	f) I take time to be generous and helpful to others Disagree	f) I take time to be generous and helpful to others Neither Agree nor Disagree	f) I take time to be generous and helpful to others Agree	f) I take time to be generous and helpful to others Strongly Agree
g) I feel very spiritual in my faith, beliefs, and culture	g) I feel very spiritual in my faith, beliefs, and culture Strongly Disagree	g) I feel very spiritual in my faith, beliefs, and culture Disagree	g) I feel very spiritual in my faith, beliefs, and culture Neither Agree nor Disagree	g) I feel very spiritual in my faith, beliefs, and culture Agree	g) I feel very spiritual in my faith, beliefs, and culture Strongly Agree
h) If needed, I could get counseling or help	h) If needed, I could get counseling or help Strongly Disagree	h) If needed, I could get counseling or help Disagree	h) If needed, I could get counseling or help Neither Agree nor Disagree	h) If needed, I could get counseling or help Agree	h) If needed, I could get counseling or help Strongly Agree
i) I get any medical services I need	i) I get any medical services I need Strongly Disagree	i) I get any medical services I need Disagree	i) I get any medical services I need Neither Agree nor Disagree	i) I get any medical services I need Agree	i) I get any medical services I need Strongly Agree
j) I often think about things I am grateful for	j) I often think about things I am grateful for Strongly Disagree	j) I often think about things I am grateful for Disagree	j) I often think about things I am grateful for Neither Agree nor Disagree	j) I often think about things I am grateful for Agree	j) I often think about things I am grateful for Strongly Agree
k) I feel close to other students at my school	k) I feel close to other students at my school Strongly Disagree	k) I feel close to other students at my school Disagree	k) I feel close to other students at my school Neither Agree nor Disagree	k) I feel close to other students at my school Agree	k) I feel close to other students at my school Strongly Agree
l) Students work together at my school	l) Students work together at my school Strongly Disagree	l) Students work together at my school Disagree	l) Students work together at my school Neither Agree nor Disagree	l) Students work together at my school Agree	l) Students work together at my school Strongly Agree
m) Students help each other at my school	m) Students help each other at my school Strongly Disagree	m) Students help each other at my school Disagree	m) Students help each other at my school Neither Agree nor Disagree	m) Students help each other at my school Agree	m) Students help each other at my school Strongly Agree

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* 20. Select the answer that best shows how well you do in each of the following situations with 1 being “not very well” and 5 being “very well”

	1 "not very well"	2	3	4	5 "very well"
How well can you succeed in cheering yourself up when an unpleasant event has happened?	How well can you succeed in cheering yourself up when an unpleasant event has happened? 1 "not very well"	How well can you succeed in cheering yourself up when an unpleasant event has happened? 2	How well can you succeed in cheering yourself up when an unpleasant event has happened? 3	How well can you succeed in cheering yourself up when an unpleasant event has happened? 4	How well can you succeed in cheering yourself up when an unpleasant event has happened? 5 "very well"
How well can you give yourself a pep talk when you feel low?	How well can you give yourself a pep talk when you feel low? 1 "not very well"	How well can you give yourself a pep talk when you feel low? 2	How well can you give yourself a pep talk when you feel low? 3	How well can you give yourself a pep talk when you feel low? 4	How well can you give yourself a pep talk when you feel low? 5 "very well"
How well do you succeed in not worrying?	How well do you succeed in not worrying? 1 "not very well"	How well do you succeed in not worrying? 2	How well do you succeed in not worrying? 3	How well do you succeed in not worrying? 4	How well do you succeed in not worrying? 5 "very well"
How well can you prevent yourself from becoming nervous?	How well can you prevent yourself from becoming nervous? 1 "not very well"	How well can you prevent yourself from becoming nervous? 2	How well can you prevent yourself from becoming nervous? 3	How well can you prevent yourself from becoming nervous? 4	How well can you prevent yourself from becoming nervous? 5 "very well"

Thank you for your help!! If you are concerned about a suicidal friend or yourself, please speak with a trusted adult in your home as soon as possible and contact Mary Wade at mwade@paulding.k12.ga.us.

You may also call the Georgia Crisis and Access Line at 1-800-715-4225 or text SCHOOL to 741741 free 24/7 crisis counseling.

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