survey

Yvonne Singer ysinger at worldnet.att.net
Sun Feb 16 19:22:44 EST 1997


                                                  Consent Form

	This research study will involve asking questions concerning emotional behavior.  Subjects will be asked to complete one short survey.  If you feel uncomfortable, feel free to discontinue at any time.  However, we do not believe there are any negative consequences that will result from this study.  At the conclusion of this study, contact YSINGER at WORLDNET.ATT.NET to receive results, which will be available upon your request.

              I agree to participate in the study.

	By responding, you have agreed to participate in the study.

Age ____		Sex ____

Directions: Answer each of the following items by typing a few sentences.

1. What is your disability?

2. Describe your current living arrangements.
   Who lives with you?

3. Describe your family relationship.
   Who are you closest to?

4. Are you able to take care of yourself?
   If no, who physically assists you on a daily basis?

5.  State the types of schools you previously and are currently attending.

6. Suppose you had to write an essay for class and  your teacher did not like your                                                     essay.  As a result, you  received an F.  The teacher gave you two options to either rewrite the essay to receive a higher grade or to accept your failing grade.  How would the teacher make you feel?

7. Was there a time when you were too upset to eat?
   If you become so upset now, would you refuse to eat?

8. What are your educational goals?
   What do you see as your highest level of education you want to achieve?

9. What are your professional goals?

10.  What are your personal goals?

     Type the number that best describes how often you felt or behaved
during the past week.

		0 = Rarely or none of the time (less than 1 day)
		1 = Some or a little of the time (1-2 days)
		2 = Occasionally (3-4 days)
		3 = Most or all of the time (5-7 days)

1. I was bothered by things that usually don't bother me. ANSWER:

2. I did not feel like eating; my appetite was poor. ANSWER:

3. I felt that I could not shake off the blues even with help from my family or friends.  ANSWER:

4. I felt that I was just as good as other people. ANSWER:

5. I had trouble keeping my mind on what I was doing. ANSWER:

6. I felt depressed.  ANSWER:

7. I felt that every thing I did was an effort.  ANSWER:

8. I felt hopeful about the future. ANSWER:

9. I thought my life had been a failure,  ANSWER:

10. I felt fearful.  ANSWER:

11. My sleep was restless.  ANSWER:

12. I was happy.  ANSWER:

13. I talked less than usual.  ANSWER:

14. I felt lonely.  ANSWER:

15. People were unfriendly.  ANSWER:

16. I enjoyed life.  ANSWER:

17. I had crying spells.  ANSWER:

18. I felt sad. ANSWER:

19. I felt that people disliked me.  ANSWER:

20. I could not get "going". ANSWER:

	Type the number that best fits the items.

		0 = None of the time
		1 = A little of the time
		2 = Some of the time
		3 = A lot of the time
		4 = Most of the time
		5 = All of the time.

1. I think I am doing pretty well. ANSWER:

2. I can think of many ways to get things in life that are most important to me.  ANSWER:

3. I am doing just as well as other people my age.  ANSWER:

4.  When I have a problem, I can come up with many ways to solve it.  ANSWER:

5. I think of things I have done in the past will help me in the future.  ANSWER:

6. Even when others want to quit, I know that I can find ways to solve the problem.  ANSWER:

	If you have any worries after responding to this survey,  do not
hesitate to seek professional counseling.  Feel free to make any additional 
comments. 





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