DO NOT PUT YOUR CREDENTIALS ON THIS DOCUMENT

1. What is your gender? _____

1. M
2. F
3. Nonbinary
4. Trans-masculine or Transgender male
5. Trans-feminine or Transgender female
6. Other __________________

2. What is your current grade level? _____

1. Grade 8
2. Grade 9
3. Grade 10
4. Grade 11
5. Grade 12
 DO NOT PUT YOUR CREDENTIALS ON THIS DOCUMENT

Respond to the various scenarios by writing in the blank space provided if you strongly disagree
(1), disagree (2), neither agree or disagree (3), agree (4), or strongly agree (5).

Answer with the number beside your choice (ex: if you disagree with the scenario, write a
2).

1. I would like to explore strange places. ___

2. I get restless when I spend too much time at home. ___

3. I like to do frightening things. ___

4. I like wild parties. ___

5. I would like to take off on a trip with no pre-planned routes or timetables. ___

6. I prefer friends who are excitingly unpredictable. ___

7. I would like to try bungee jumping. ___

8. I would love to have new and exciting experiences, even if they are illegal. ___

A number of statements which people have used to describe

themselves are given below. Read each statement and then

Almo
Almo
check the appropriate box to the right of the statement to

Som
indicate how you generally feel. There are no right or wrong

st al
st ne

answers. Do not spend too much time on any one statement

et im

Oft e

ways
but give the answer which seems to describe your present
ver

es
feelings best.

n
21. I feel pleasant
22. I feel nervous and restless
23. I feel satisfied with myself
24. I wish I could be as happy as others seem to be
25. I feel like a failure
26. I feel rested
27. I am "calm, cool, and collected"
28. I feel that difficulties are piling up so that I cannot
overcome them
29. I worry too much over something that really doesn't matter
30. I am happy
31. I have disturbing thoughts
32. I lack self-confidence
33. I feel secure
34. I make decisions easily
35. I feel inadequate
36. I am content
37. Some unimportant thought runs through my mind and
bothers me
38. I take disappointments so keenly that I can't put them out
of my mind
39. I am a steady person
40. I get in a state of tension or turmoil as I think over my
recent concerns and interests
 DO NOT PUT YOUR CREDENTIALS ON THIS DOCUMENT

What causes stress in your life? Place a check beside all situations that apply.

1. School Work ___

2. Social media ___

3. Bullying ___

4. Dating ___

5. Home environment ___

6. Employment responsibilities ___

7. Financial status ___

8. Extra-curricular activities (Sports, clubs, independent studies, during or after school) ___

9. Self judgement ___

10. Social acceptance ___

11. Relationship with adults (family, teachers, etc.) ___

12. Mental illness (PTSD, anxiety disorder, own or someone else’s) ___

13. Physical illness (Own or someone else’s) ___

14. Other (please specify) _________________