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- What's your birthday?*
- What's your gender?
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Format: (000) 000-0000.
- Primary language:
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Format: (000) 000-0000.
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- What is your parent or guardian's birthday?
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- I feel safe and secure at home.*
- I care about school.*
- I stay away from tobacco, alcohol, and other drugs.*
- Money is not a stressor in my family.*
- I overcome challenges in positive ways.*
- I feel good about myself.*
- I have friends who set good examples for me.*
- I have adults who are good role models for me.*
- I feel in control of my life and future.*
- I have a family that gives me love and support.*
- I feel valued and appreciated by others.*
- Have you ever been in trouble with the law?*
- Have you ever been in residential treatment?*
- Do you or your family participate in programs like free or reduced-price lunch at school? If you're not in school, do you feel like your family struggles financially to make ends meet?*
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- Should be Empty: