Pre-Match Kidcope Survey

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Please complete this form prior to your initial meeting with your mentor.

Name *

I though about something else; tried to forget it; and/or went and did something like watch TV or play a game to get it off my mind. *

Yes

I though about something else; tried to forget it; and/or went and did something like watch TV or play a game to get it off my mind. *

Yes

I stayed away from people; kept my feelings to myself; and just handled the situation on my own. *

Yes

I tried to see the good side of things and/or concentrated on something good that could come out of the situation *

Yes

I realized I brought the problem on myself and blamed myself for causing it. *

Yes

I realized that someone else caused the problem and blamed them for making me go through this. *

Yes

I thought of ways to solve the problem; talked to others to get more facts and information about the problem and/or tried to actually solve the problem. *

Yes

I talked about how I was feelings; yelled; screamed; or hit something. *

Yes

I tried to calm myself by talking to myself, praying, taking a walk , or just trying to relax. *

Yes

I kept thinking and wishing this never happened; and/or that I could change what had happened. *

Yes

I turned to my family, friends, or other adults to help me feel better. *

Yes

I just accepted the problem because I knew i couldn't do anything about it. *

Yes

Date *

YYYY

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