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Questions marked with a * are required Exit Survey
 
 
* What is your age rage
 
Under 11
 
11-13
 
14-16
 
17-19
 
20-23
 
24-27
 
28+
 
 
 
* On a weekly basis about how many times do you find yourself uninterested in daily activitie?
 
0-1
 
2-3
 
4-5
 
All week
 
 
 
* Do you struggle in school or at work
 
Yes
 
No
 
 
 
* Do you feel safe when you go to school/work
 
Yes
 
No
 
 
 
* Have you been professionally diagnosed with any form of mental illness/disorder (Depression.Anxiety,Bi-polar disorder,Etc.)
 
Yes
 
No
 
 
 
* If so, which mental illnesses/disorders (Select all that apply)?
 
Depression
 
Anxiety
 
Bipolar
 
Eating disorder (anorexia, bulimia)
 
Insomnia/Nightmare
 
Paranoia
 
Alcohol abuse/dependence
 
Substance abuse/dependence

 
 
 
* When were you diagnosed with your mental illness/disorder
 
Before starting school/work
 
During school/work
 
After school/work
 
 
 
* Have you ever thought or attempted suicide
 
Yes
 
No
 
 
 
* Have you ever harmed yourself physically?
 
Yes
 
No
 
 
 
* Have you ever seeked help?
 
Yes
 
No
 
To scared to
 
Unable to