Q. From what you know about Venture Academy's Independent Living Program, how motivated are you to attend and follow through with the program? 1. I'm really excited, can't wait to participate. 2. It should be good; I'm looking forward to it. 3. My parents are behind this; I don't want to go. 4. I know it will be good for me but I don't want to leave my family and friends.

Q. When you're with your friends, would you describe yourself as someone who, 1. Generally suggests what the group should do. 2. Listens to ideas from others and gives suggestions as well. 3. Goes along with the groups decision. 4. Does what I want no matter what is suggested.

Q. At home, how would you say your family gets along? 1. We are probably typical. We have our ups and downs. 2. Sometimes things seem tense but we usually seem to pull through. 3. Lots of conflict. It feels like we just need a break. 4. Everyone always treats each other with respect and consideration.

Q. What best describes your role in you helping out where you live right now? 1. I've got better things to do, they don't count on me for help. 2. I'll do it if I have to, the sooner it's done, the sooner I get to do what I want. 3. I'll help with my part; everyone needs to do his or her share. 4. When I'm done I'll gladly help others until the whole job is finished.

Q. You probably have some kind of work experience. Which of the following describes it the best? 1. Helped out around the house, cleaned up, yard work, etc. 2. Have worked for others and got paid, nothing official though. 3. I've had or do have a part or full-time job.

Q. At school, or when you went to school how would you describe yourself in class? 1. I'm always studying hard and get my assignments done on time. 2. School hasn't been or never was great. I'm always getting in trouble or have a history of suspensions. 3. I'm currently kicked out or have quit school. 4. With help or when I put my mind to it I can complete the work assignments. 5. I have trouble concentrating and get bored easily.

Q. List your 5 favorite sporting and outdoor activities in order.

Q. Please list 5 other interests or hobbies you may have.

Q. If someone in a position of authority asks you to do something, how do you usually respond? 1. Do what they say, no questions asked. 2. Depends what it is; I may want to ask some questions first. 3. I don't like people telling me what to do and probably won't do it. 4. Go along with it, even though I may not like it.

Q. If you're facing a problem or some kind of difficulty, how do you deal with it? 1. Go with my first instinct and act on what initially comes to mind. 2. Gather more information and try to solve it on my own. 3. Look to others for help if needed. 4. Just avoid it altogether.

Q. What best describes your history of dealing with situations where you have been angry? 1. Just walk away. I won't even bother dealing with that person. 2. Might yell or lash out at somebody. 3. Let the person know how I'm feeling and ask to talk about it later when I've calmed down

Q. What best describes your drug or alcohol use? 1. Never touch the stuff. 2. I'll do it when it's around, like at parties or on special occasions. 3. Come to think of it, fairly regular, at least once a week. 4. I use a lot. I'm usually doing it daily. 5. I have experimented, but its not something I'd do again.

Q. List 5 positive qualities about yourself.

Q. List 5 things about yourself you'd like to improve.

Q. Have you ever been to counselling or gone for any kind of psychological or educational assessments? 1. Yes 2. No

Q. When you set out to accomplish something how does it usually turn out? 1. I'm a real "go-getter", I always reach my goals. 2. Depends on how serious I am or how big the job is. Sometimes things are just too overwhelming. 3. I get excited at first, but usually end up not following through with things. 4. I've never really accomplished anything, I usually end up failing most everything. 5. I try my best and that's what matters. If I reach my goal, it's an added bonus.

Q. Why do you wish to participate in Venture Academy's Independent Living Program?

Q. What else can you tell us about yourself in order for us to get to know you better?

Q. Did anyone help you fill out this survey? If so, who? Yes   No Name:   (last name optional)

Would you like us to contact you? 1. Yes 2. No

Contact Information

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