SAMPLE SURVEY

The actual survey can be found at TreeHouseSurvey.com

Contact Info

Please update your contact info.

Email Address

Cell Phone

Shirt Size (for free t-shirt below!)

Contact Info

Please add your info so that you can complete the survey!

First Name

Last Name

Email Address

Cell Phone

Shirt Size (for free t-shirt below!)

Date of Birth

Site Account ID

Teen ID

First Name

Full Name

Contact Pass through?

What Grade Are You In?

Site Type

Partner Site

Since this is your last TreeHouse survey, we might as you a few extra questions at the end to help us support you in the future!

What types of careers might you be interested in for the future?

Would you say you're on track to graduate?

Using this scale, rate how true these statements are for you.

How much do you feel...

Your friends at TreeHouse care about you?

Adults at TreeHouse care about you?

You give support to your peers or friends when they need it?

Adults at TreeHouse understand your family's culture?

Now we're moving on to questions about how you respond to your emotions and challenges.

In general, how does each of the following statements describe you?

I find good ways to deal with things that are hard in life.

I express my feelings in proper ways.

I stand up to peer pressure when I feel something is not right.

I have goals for my life.

I feel in control of my life and future.

I feel good about my future.

We'd love to hear where you're at with God.

We're not judging, we just want to hear from you!

In general, how does each of the following statements describe you?

I believe God exists.

I believe that God loves me.

My belief in God affects how I live my life.

I want to learn more about God.

Now let's talk about how you feel about yourself and your future.

I feel good about myself.

I believe I am lovable, capable and worthwhile.

I think I can affect other people's lives.

We care about your mental health!

Tell us how you experience these common challenges.

During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in

a row that you stopped doing some usual activities?

Do you have any long-term mental health, behavioral or emotional problems? Long-term means lasting 6

months or more.

Have you ever been treated for a mental health, emotional or behavioral problem?

In the past TWO WEEKS, have you...

Felt sad or depressed for several hours?

Been bothered by not being able to pay attention when you were in class or doing homework or reading a book or playing a game?

Felt angry or lost your temper?

Not been able to stop worrying?

How do you feel the following statements describe you?

I am worried about the upcoming presidential election

I'm afraid I might experience violence at school

I feel like I'm doing well in school

What do you like most about TreeHouse? What keeps you coming?

What would make TreeHouse better?

Finish the sentence: "Because of TreeHouse, I..."

Now let's talk about what's been going on in your life.

Remember, this is confidential.

Had an alcoholic beverage (beer, wine, liquor, etc.)?

In the past TWO WEEKS, have you...

Used tobacco products (cigarette, vape, cigar, pipe, snuff, chewing tobacco)?

Used drugs like marijuana, cocaine or crack, club drugs (like Ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?

Used any medicine without a doctor’s prescription to get high or change the way you feel

(e.g., painkillers [like Vicodin], stimulants [like Ritalin or Adderall], sedatives or tranquilizers

[like sleeping pills or Valium], or steroids)?

Thought about killing yourself or committing suicide?

Bullied others?

Had sexual intercourse or oral sex?

Been a target of a bully?