SUCCEED Pre-Survey
Date
*
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Month
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Day
Year
Date
School Name
*
Grade
*
Age
*
Gender
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Female
Male
Transgender
Other
Prefer not to say
Gender- If Other Please Define
Race/Ethnicity
*
Asian or Asian American
Latino or Hispanic
African American or Black
White/Caucasian/Anglo/ European American; not Hispanic
American Indian or Native American
Biracial
Other
Unknown
Race/Ethnicity- If Other Please Define
Household income
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Less than $25,000
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 to $199,999
$200,000 or more
I don’t know
How many people in household
*
What are your problems right now
Depression
Anxiety
Anger
Bullying
Drugs/Alcohol
Family Issues
Academic/School Issues
Social/School Issues
Please tell us how this SUCCEED group can be helpful to you
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