Please Help

I need help for school please fill out this survey and email it to me at jessikanelson@rocketmail.com (my school email) it will be totally anonymous so please answer as honestly as possible! if you would rather fill it out by hand i can give you a copy that you can fill out and get back to me also pass it on to anyone you can the more results we get the better our project will turn out!!! which means the better grade i get:) If you help you will definitely be my favorite person in the world!!! :) thank you mucho!!!



1. Male or Female?

2. Age:
Under 18
19-21
22-30
31-40
Over 40

3. Culture and/or ethnicity _______________________________________________

4. How well would you say you are at handling crisis? (1 no good—10 amazing)
1 2 3 4 5 6 7 8 9 10

5. Have you ever been to a counselor, psychologist, or therapist? Yes No
If YES: How did you find them or decide to go to them? And did it help? ___________
_____________________________________________________________________
If NO: Would you be willing to talk to one? Yes No

6. What kinds of crisis have you experienced (as it relates to yourself, family or friend)?
__ Cancer/ Chronic Illness __ Financial
__ Death of a close friend __ Divorce
__ Death in nuclear Family __ Self Harm
(Parents, spouse, kids, siblings) (Self mutilation, eating disorders)
__ Death in extended family __ Rape/Abuse
__ Suicide Attempt __ Pregnancy
__ Substance Abuse __ Teen Pregnancy
__ Natural Disaster __ wedding
__ Depression __ moving
__ School Problems __ Prison
__ Break in (car, house…) __ Job loss
__ Job promotion __ Accident
__other

7. Rank the difficulty of the crisis (1 being the worst thing ever)
8. Circle any of the above crises that you sought help for.
Comments:


9. In regards to the worst crisis:
If you sought help, did it help? _____________________________________
Would you do things the same way next time? Why? ________
__________________________________________________
If you did not get help: why didn’t you?
Would you do things different next time? Why? ____________
___________________________________________________
10. Was everyone involved willing to get help? Was there some pushing to or away from help? __________________________________________________________________
_______________________________________________________________________

11. How long did the Crisis last?
A few days over 6 months- 1 year
1 week -1 month over 1 year-2 years
Over 1 month- 6 months over 2 years/ continual

12. What was your first reaction to the crisis?


If you did not receive help at first at what point did you? Why?



13. Who would you be most comfortable going to get help from in a crisis?
Parent Extended family member
Sibling Therapist/ Counselor
Friend Random stranger
Teacher Police or social worker
Help Line Other: ____________________

14. If you or your friend was dealing with rape or abuse would you be more willing to talk to:
Friend Random person
Family Therapist/ Counselor
Police Help line
No one Other _________

15. Boundaries: Who was “in the know”? Do you let everyone in?
__All Family included?
__All Friends included?
__Certain friends excluded? Why? __________________________
__Certain Family excluded? Why? __________________________
__Random people included?
__No one included (kept to self)
__ One person included? Who? Why? _________________________

16. What resources do you know of to help in trauma and crisis?


17. Anything else to share?