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13th JD Youth Diversion Screening
For Youth in Kit Carson, Logan, Morgan, Phillips, Sedgwick, Washington, and Yuma Counties in Colorado
104
Questions
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1
Name of Youth
*
This field is required.
First Name
Last Name
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2
Date of Birth
*
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Youth's birthdate
-
Date
Month
Day
Year
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3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
County
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5
Parent Name
First Name
Last Name
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6
Parent Phone
example@example.com
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7
Case Number
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8
Primary Concerns
select all that apply
Alcohol
Sexting
Vaping
Fighting
Substance Use
Stealing
Behavior at School
Other
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9
Agreement Date
-
Date
Month
Day
Year
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10
Review Date
-
Date
Month
Day
Year
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11
Agreement
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
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12
Does your relationship with your family involve frequent/intense conflict or are you alienated/assaultive with each other?
YES
NO
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13
Please explain:
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Small
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14
Have you ever been assaultive?
Have you made a verbal or physical assault on someone?
YES
NO
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15
Please explain:
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16
Have you used drugs with in the past year?
YES
NO
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17
Please explain:
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18
Have you missed more than 10 days of school in the past year?
YES
NO
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19
Please explain:
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20
As of today, are you NOT enrolled in school?
Public, private, online, or home school
YES
NO
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21
Please explain:
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22
Have you been diagnosed with a behavioral or mental health issue?
YES
NO
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23
Please explain:
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24
Do your friends get in trouble with law enforcement?
YES
NO
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25
Please explain:
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26
Have you ever run away from home?
This includes your foster care setting, if applicable
YES
NO
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27
Please explain:
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Small
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28
Is your current court charge a "status offense"?
Meaning, it wouldn't be a crime if you were an adult
YES
NO
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29
Please explain:
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Small
Ok
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Created with Sketch.
Ok
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30
Is this your first offense, or do you have prior complaints before this one?
YES
NO
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31
Please explain:
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32
Score
Each of the above YES answers count as 1 point
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
Based on the Arizona Risk/Need Assessment Instrument
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33
Name of your School
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34
Current Grade Level
6th
7th
8th
9th
10th
11th
12th
Other
6th
7th
8th
9th
10th
11th
12th
Other
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35
How many days have you been absent in the past year?
Less than 5 Days
5-15 Days
More than 15 Days
Less than 5 Days
5-15 Days
More than 15 Days
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36
Have you ever been assigned in-school detention?
YES
NO
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37
Have you ever had an out-of-school suspension?
YES
NO
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38
What are your current grades in school?
Straight As
Mostly As and Bs
Mostly Bs and Cs
Mostly Cs and Ds
Mostly Ds and Fs
Failing All Classes
Straight As
Mostly As and Bs
Mostly Bs and Cs
Mostly Cs and Ds
Mostly Ds and Fs
Failing All Classes
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39
Do you have a current IEP in place at your school?
YES
NO
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40
Are you working with a school counselor for social-emotional learning skills?
YES
NO
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41
What is their name?
Name of the person at your school that helps you with behavior skills
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42
Are you currently seeing a professional counselor or therapist?
YES
NO
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43
Your Diagnosis
Depression
Anxiety
ADD
ADHD
ODD
PTSD
OCD
Bipolar
Other
Not Sure
Depression
Anxiety
ADD
ADHD
ODD
PTSD
OCD
Bipolar
Other
Not Sure
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44
Medications Prescribed
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45
Type(s) of Services
What kind of things are you doing with your counseling program?
Individual Therapy Sessions
Group Therapy Sessions
Mentoring
Life Skills (case manager)
Substance Use Treatment
Addiction Recovery Group
Transition to Independence
Support Group (general)
Family Therapy
Family Support Group
Other
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46
Typical Counseling Schedule
Twice a Week
Once a Week
Twice a Month
Once a Month
Every other month
Random times
Whenever I ask
No idea
Twice a Week
Once a Week
Twice a Month
Once a Month
Every other month
Random times
Whenever I ask
No idea
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47
Name of Counselor
First Name
Last Name
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48
Agency
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49
Counselor's Email
example@example.com
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50
Phone Number
Area Code
Phone Number
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51
Does your family have an open Child Welfare case?
YES
NO
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52
Which County?
Which county Dept. is managing your case?
Kit Carson
Logan
Morgan
Phillips
Sedgwick
Washington
Yuma
Other
Kit Carson
Logan
Morgan
Phillips
Sedgwick
Washington
Yuma
Other
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53
Name of your Caseworker:
First Name
Last Name
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54
Caseworker's Email
example@example.com
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55
Caseworker's Phone Number
Area Code
Phone Number
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56
Are you currently placed in Foster Care?
YES
NO
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57
Are you a victim of sexual assault?
YES
NO
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58
Are you a sex offender?
YES
NO
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59
Have you been a witness to or victim of Domestic Violence?
YES
NO
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60
Do you have a Victim's Advocate?
YES
NO
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61
What is your Victim's Advocate's Name?
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62
Does your family have plenty of food every day?
YES
NO
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63
Do you currently have a safe home to live in? (front door, windows, electricity, showers, heat, etc.)
YES
NO
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64
Would you like information about any of these assistance programs?
Please select all that apply:
Food Stamps
LEAP (home heating bills)
TANF
Diversion
Employment First
Cooperating Ministries
Your Church
Other
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65
Do you have friends who smoked cigarettes or vaped nicotine in the past year?
YES
NO
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66
Do you have friends who drank alcohol in the past year?
YES
NO
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67
Do you have friends who have smoked weed, vaped marijuana, or consumed marijuana edibles in the past year?
YES
NO
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68
Do you have friends who have used "hard drugs" in the past year?
Crack, cocaine, etc.
YES
NO
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69
Do you have friends who have taken prescription meds to get high in the past year?
YES
NO
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70
Do you have friends who have used over-the-counter drugs to get high in the past year?
Cough syrup, Dramamine, etc.
YES
NO
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71
Have YOU smoked cigarettes or vaped nicotine in the past year?
YES
NO
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72
How often do you smoke or use nicotine?
Please enter the approximate number of days in the box
How many times?
Past Week
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Past Month
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Past 3 Months
Row 2, Column 0
Past Year
Row 3, Column 0
Past Week
Past Month
Past 3 Months
Past Year
How many times?
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73
Have YOU drank alcohol in the past year?
YES
NO
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74
How often do you drink alcohol?
Please enter the approximate number of days in the box
How many times?
Past Week
Row 0, Column 0
Past Month
Row 1, Column 0
Past 3 Months
Row 2, Column 0
Past Year
Row 3, Column 0
Past Week
Past Month
Past 3 Months
Past Year
How many times?
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75
Have YOU sniffed or huffed to get high in the past year?
glue, aerosol, etc.
YES
NO
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76
How often do you huff to get high?
Please enter the approximate number of days in the box
How many times?
Past Week
Row 0, Column 0
Past Month
Row 1, Column 0
Past 3 Months
Row 2, Column 0
Past Year
Row 3, Column 0
Past Week
Past Month
Past 3 Months
Past Year
How many times?
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How many times?
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How many times?
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How many times?
Row 3, Column 0
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77
Have YOU smoked weed, juul'd marijuana, or consumed marijuana edibles in the past year?
YES
NO
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78
How often do you use marijuana?
Please enter the approximate number of days in the box
How many times?
Past Week
Row 0, Column 0
Past Month
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Past 3 Months
Row 2, Column 0
Past Year
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Past Week
Past Month
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79
Have YOU used "hard drugs" in the past year?
Meth, crack, cocaine, etc.
YES
NO
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80
Which "hard" drugs have you used in the past year?
Cocaine or Crack
Heroin
Meth or other Amphetamines
Hallucinogens (LSD, mushrooms)
Inhalants (Vape)
Other
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81
How often do you use hard drugs?
Please enter the approximate number of days in the box
How many times?
Past Week
Row 0, Column 0
Past Month
Row 1, Column 0
Past 3 Months
Row 2, Column 0
Past Year
Row 3, Column 0
Past Week
Past Month
Past 3 Months
Past Year
How many times?
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How many times?
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How many times?
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82
Have YOU used prescription meds to get high in the past year?
YES
NO
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83
Which prescription meds do you usually use?
Prescription Pain Relievers (Vicodin, Oxycontin, Dilaudid, Percocet, etc.)
Prescription Sedatives (Valium, Xanax, Ativan, Klonopin, etc.)
Prescription Stimulants (Adderall, Ritalin, etc.)
Other
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84
How often do you use prescription meds to get high?
Please enter the approximate number of days in the box
How many times?
Past Week
Row 0, Column 0
Past Month
Row 1, Column 0
Past 3 Months
Row 2, Column 0
Past Year
Row 3, Column 0
Past Week
Past Month
Past 3 Months
Past Year
How many times?
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How many times?
Row 1, Column 0
How many times?
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How many times?
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85
Do YOU use over-the-counter meds to get high in the past year?
Nyquil, Benadryl, cough meds, sleeping pills, etc.
YES
NO
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Enter
86
How often do you use over-the-counter meds to get high?
Please enter the approximate number of days in the box
How many times?
Past Week
Row 0, Column 0
Past Month
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Past 3 Months
Row 2, Column 0
Past Year
Row 3, Column 0
Past Week
Past Month
Past 3 Months
Past Year
How many times?
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How many times?
Row 1, Column 0
How many times?
Row 2, Column 0
How many times?
Row 3, Column 0
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87
How would you rate how your life is going, overall?
0
1
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3
4
5
6
7
8
9
10
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88
In the past 2 weeks, how often have you felt depressed, irritable, or hopeless?
Not at all
1
2
some days
4
5
6
more than half
8
9
Every Day
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Not at all
1
2
some days
4
5
6
more than half
8
9
Every Day
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89
In the past 2 weeks, how often have you found it hard to care about doing anything, or felt like nothing is enjoyable?
Not at all
1
2
some days
4
5
6
more than half
8
9
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90
In the past 2 weeks, how often have you had trouble sleeping, or have slept too much?
Not at all
1
2
some days
4
5
6
more than half
8
9
Every Day
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1
2
some days
4
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6
more than half
8
9
Every Day
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91
In the past 2 weeks, how often have you felt tired or had no energy?
Not at all
1
2
some days
4
5
6
more than half
8
9
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1
2
some days
4
5
6
more than half
8
9
Every Day
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92
In the past 2 weeks, how often have you thought of hurting yourself in some way?
Not at all
1
2
some days
4
5
6
more than half
8
9
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Not at all
1
2
some days
4
5
6
more than half
8
9
Every Day
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93
Has there been a time in the past month when you have had serious thoughts about ending your life?
YES
NO
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94
Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?
YES
NO
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95
Good Things at School
Favorite Teacher
Favorite Class
Favorite Activity (sport, music, club, etc.)
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96
Your People
Favorite Family Members
Favorite Friends
Favorite Coach or Church person, etc.
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97
Your Talents
Something you're good at
Something you're good at
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98
Your Hobbies
Something you enjoy doing
Something you enjoy doing
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99
Your Favorites
Favorite Movie
Favorite Song right now
Favorite Sports Team
Favorite TV Show
Favorite Color
Favorite Holiday
Favorite Book
Favorite Food
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100
Possible Career Plans
What are a couple of ideas for how you would like to earn a living?
Future Career Idea
Future Career Idea
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101
Comments
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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102
Email to use for login
example@example.com
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103
Password
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104
Phone Number
Area Code
Phone Number
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