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Who do you live with?
 
Parents
 
Guardians
 
Family
 
Friends
 
On my own
 
 
 
Do you have a child (children) of your own?
 
What are their age(s): ________
 
 
 
Do you have any health issues that keep you away from school?
 
 
 
 
How many hours of sleep do you get at night?
 
 
 
 
How do you get to school?
 
 
 
 
What is your motivation for earning a high school diploma?
 
I HAVE to come to school
 
I want to go to college
 
I want to get a better job
 
 
 
What is your plan for after school?
 
More education
 
Employment
 
 
 
What kind of tests or quizzes do yiu prefer?
 
Multiple choice
 
Short answer
 
Essay questions
 
Class presentation
 
 
 
Name a person or people who have been a positive influence in your life:
 
_____________________________________________
 
 
 
Have you ever felt like talking with a counselor about a difficult issue or life experience?
 
 
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