Pre-Self-Inventory
Please answer the questions below as honestly as possible.  Your answers will be kept confidential
Email *
1. What is your school / organization?
2. How many years have you been a member of ROSE?
Clear selection
3. How many girls in your school prior to being in ROSE have you confided in about personal issues? *
4. How many adults in your school do you feel you can confide in about personal issues? *
5. How many fights have you had in the past year? *
6. How many verbal disagreements have you had in the past year?? *
7. Have you been suspended during your high school years?
Clear selection
8. Have you ever had any involvement with law enforcement?
Clear selection
8. Rate yourself on the following (with 0 being the lowest and 5 being the highest) *
1
2
3
4
5
NA
Self-Esteem
Self-Love
Leadership
Communication Skills
Confidence
Getting along with others
Perserverance
Motivation
9. Have you been directly impacted by any of the following? Check yes or no.  Also check 'need more information' if you don't know where to get resources on the topic for yourself or someone else. *
Yes
No
Need More Information
Bullying
Gangs
Date Rape
Sexual Assault
Conflict Resolution
Human Trafficking
Depression
Eating Disorders
School Failure
Substance Abuse
Family Member Arrested or Incarcerated
Police Interactions
10. Answer the following questions
yes
no
Do you have trouble making friends?
Does your shyness prevent you from trying new things?
Do you have someone that you confide in?
Are you dealing with issues that impact your ability to focus in school?
Have you ever been bullied?
Do you have issues communicating with peers?
Do you have issues communicating with adults?
Have you ever felt targeted by a system?
Have you ever felt hopeless?
Clear selection
11. If you have been in ROSE before this year what areas have you grown in as a result of being in the program?
12. What do you hope to gain from being in this program? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms