Natural Helpers Survey Names

Adults

Please submit the names of two adults AT THIS SCHOOL you trust and with whom you feel comfortable talking about a personal problem:

Last Name: First Name: Dept.
Last Name: First Name: Dept.

Students

Please submit the names of two students AT THIS SCHOOL you trust and with whom you feel comfortable talking about a personal problem:

Last Name: First Name: Grade
Last Name: First Name: Grade

Enter your student ID

I am:  Female  Male I am in Grade  8  9 10 11 12

Select the top 5 concerns that you believe are major issues for you and your friends by putting a check mark in the box preceding the concern.

Gossip/Rumors Relationships/Dating
Money (School/Living Expenses) Family (Conflicts)
Fighting/Bulling College and Career Choices
Sexual Identity/Orientation Sexual Harassment
Abuse (Physical/Sexual/Emotional) Dating Violence World Issues (War/Hunger/Violence)
Depression/Loneliness Prejudice/Discrimination
Sex-Related Concerns (Peer Pressure/Pregnancy/Birth Control) Addictions (Drugs/Alcohol Gambling/Eating Disorders)
Overall Stress (Pressures) Fitting In/Self-Image
Loss (Separation/Death/Divorce) Suicide/Self-Destructive Actions
Achievement in School (Grades)   Other:  Please Indicate