SUCCEED Post-Survey
Date
*
-
Month
-
Day
Year
Date
School Name
*
Grade
*
Age
*
Gender
*
Please Select
Female
Male
Transgender
Other
Prefer not to say
Gender- If Other Please Define
Race/Ethnicity
*
Please Select
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
*
Please Select
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
*
I have goals and plans for my future that I feel good about.
0
1
2
3
4
Worst
Best
0 is Worst, 4 is Best
I am aware of my emotions/feelings.
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
I feel good about the kind of person I am.
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
I have a good relationship with my family.
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
I have good relationships with my friends.
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
I have healthy coping skills for dealing with depression/anxiety/anger.
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
At the beginning of this group, I was struggling with depression/anxiety/anger
True
False
N/A
At the beginning of this group, I was using alcohol/drugs/nicotine
True
False
N/A
Since beginning this Succeed group, I am using drugs/alcohol less than often
True
False
N/A
Since beginning this Succeed group, I have stopped using drugs/alcohol
True
False
N/A
Since beginning this Succeed group, my ability to cope with stress improved
True
False
N/A
I have a better awareness of my drug/alcohol use
True
False
N/A
I have a better understand why other people use drugs/alcohol
True
False
N/A
I am making better grades this semester than last semester
True
False
N/A
I am attending school more regularly this semester than last semester
True
False
N/A
I am more satisfied with my relationships with friends and/or family
True
False
N/A
I feel better about myself and my future
True
False
N/A
I think this group has been helpful
True
False
N/A
Please tell us in your own words how this Succeed group has been helpful for you?
How can we improve this Succeed group in the future?
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