Participant Questionnaire
Participant Questionnaire
Name
Date of Birth
/
Month
/
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
In Case of Emergency, Call This Person
Emergency Contact Phone Number
Emergency Contact's Relationship to Me
Grade in School Year 2023/2024
Please Select
7th grade
8th grade
9th grade
10th grade
School Attending:
Pronouns
He/Him
She/Her
They/Them
Interests/Hobbies - What Brings You Joy?
Prescription Medications
Do you/have you ever seen a therapist?
Yes
No
Do you exercise regularly?
Yes
No
If so, how often?
Please Select
1 day/week
2 days/week
3 days/week
4 days/week
5 days/week
6 days/week
7 days/week
What do you do to exercise? (i.e. run, lift weights, dance, swim, bike, etc.)
How would you describe your eating habits?
Not healthy
Okay
Healthy
What do you typically eat for breakfast?
What's for lunch?
What do you eat for dinners?
What foods do you like to snack on?
What time do you typically go to sleep?
What time do you typically wake up?
How would you describe your sleep?
Sleep restfully
Have a hard time falling asleep
Have a hard time staying asleep
Have a hard time waking up
Other
How much time do you spend on your phone each day other than for homework?
1-3 hours
3-5 hours
5-8 hours
8+ hours
Why have you joined EMPOWERMENT? What do you hope to get out of it?
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