How I See Me

This survey was developed with you in mind. It is important for “you” to learn more about you and how you see yourself. Feel about yourself and think about yourself. By exploring “you,” you can discover what issues are most of value and or of importance to you as individuals. How you think of yourself. This survey will ask a range of questions from health, looks, attitude, relationships and personal values. Real issues you deal with in everyday life. Answer the following questions honestly. This is a self reflection. Who do you see when you look in a mirror? After all, you’re answering questions about “How I See Me.”

In no way will your answers be used to and or for any type of consequence or punishment. You will not be judged or viewed differently because of your honesty and courage to share. Information you provide will be collected and reviewed so that the supports that are provided for you on campus are what “you” determine you need to succeed in life.

Name


A red asterisk (*) indicates required questions.


  1. Age  *


  1. Gender: 


  1. Ethnicity


  1. Advisory


  1. I live with:
    Both parents
    Stepparent
    Foster parent
    Grandparents
    Sister/brother
    One parent
    Uncle/aunt
    Other


  1. How do you feel about yourself? 


  1. Do you find yourself: Pick one that best describes you. 


  1. What do you like the most in others? 


  1. What do you like the most in yourself? 


  1. How satisfied are you with your looks? 


  1. Do you think the media plays a big part in how you look, feel and think of yourself?
    Yes
    No


  1. How important are looks when it comes to making friends? 


  1. How important are looks when it comes to success? 


  1. How important are looks when it comes to getting respect? 


  1. Which of the following would make you feel better about yourself? (check all that apply)
    Getting better grades
    Losing weight
    Having a better relationship with my parents
    Bulking up or toning up
    Doing better in sports
    Wearing name brand clothing
    Fitting in with a certain crowd
    Quitting smoking
    Quitting drugs and or alcohol
    Nothing; I like myself the way I am


  1. How pressured do you feel to drink alcohol? 


  1. How pressured do you feel to smoke? 


  1. How pressured do you feel to take illegal drugs? 


  1. How pressured do you feel to have sex? 


  1. How pressured do you feel to ditch school? 


  1. How pressured do you feel to have a girlfriend/boyfriend? 


  1. How pressured do you feel to look a certain way? 


  1. Who understands you the most? 


  1. How much influence do your parents have on your life? 


  1. How much influence does your boyfriend/girlfriend have on your life? 


  1. How much influence do your teachers have on your life? 


  1. How much influence does religion have on your life? 


  1. How much influence does advertising have on your life? 


  1. How much influence do music channels have on your life? 


  1. How much influence do TV shows have on your life? 


  1. How much influence do peers have on your life? 


  1. How much influence do celebrities have on your life? 


  1. Do you have an adult you can confide in, outside or in your family?
    Yes
    No


  1. Do you think adults generally value your opinion?
    Yes
    No


  1. Do you consider yourself healthy?
    Yes
    No


  1. When is the last time an adult, such as a teacher or parent, said something encouraging or supportive to you? 


  1. How often do you have a conversation with one of your parents that last longer than 15 minutes? 


  1. How does your race or ethnicity affect the way you feel about yourself? 


  1. 2 million teens suffer from severe depression or sadness, according to one estimate researched by USA Weekend Magazine. Do you ever feel depressed? 


  1. Have you ever visited a mental health counselor?  


  1. Have any of your friends ever tried to commit suicide, or discussed it?
    Yes
    No


  1. Do you know of anyone who completed suicide?
    Yes
    No


  1. Have you thought about or attempted suicide?
    Yes
    No


  1. Have you ever taken prescribed anti-depressant drugs?
    Yes
    No


  1. Which of the following after school activities are you involved in? (Check all that apply)
    Athletics
    Any of the Assets programs
    Youth groups (church, scouts, community group)
    Music, art, signing (private lessons)
    Work part time
    Volunteer
    Tutoring
    No after-school activity