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Keys Empowers
POSIT
Step
1
of
2
50%
Consumer Name:
(Required)
First
Last
DOB:
(Required)
Month
Month
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Day
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Year
Year
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Staff Email:
(Required)
Has the consumer received a COVID-19 Vaccine?
Yes
No
Has the consumer received a COVID-19 Vaccine?
1st Dose
1st & 2nd Dose
1st & 2nd Dose with Booster
Prefer not to say
Have you had so much energy you don't know what to do with it?
(Required)
No
Yes (C)
Were most of your friends younger than you are?
(Required)
Yes (E)
No
Did you cut at least 5 days of school?
(Required)
Yes (C)
No
Have your parents or guardians liked talking with you and being with you?
(Required)
Yes (D)
No
Have any of your best friends participated in team sports which require regular practices?
(Required)
Yes (I)
No
Have you been pleased with how well you have done in activities with your friends?
(Required)
Yes
No (H)
Did alcohol or drug use cause your moods to change quickly like from happy to sad or vice versa?
(Required)
Yes (A)
No
Have you felt sad most of the time?
(Required)
Yes (C)
No
Did you have a car accident while high on alcohol or drugs?
(Required)
Yes (D)
No
Have you forgotten things you did while drinking or using drugs?
(Required)
Yes (A)
No
Have you driven a car while you were drunk or high?
(Required)
Yes (A)
No
Have you and your parents or guardians had frequent arguments which involved yelling and screaming?
(Required)
Yes (D)
No
Have you had trouble concentrating?
(Required)
Yes (C)
No
Did you hear things no one else around you heard?
(Required)
Yes (C)
No
Have you had trouble with your breathing or with coughing?
(Required)
Yes (B)
No
Did people your own age like and respect you?
(Required)
Yes
No (H)
Have you had a constant desire for alcohol or drugs?
(Required)
Yes (A)
No
Did you act on the spur of the momebt
(Required)
Yes (C)
No
Did you exercise for a half hour or more at least once a week?
(Required)
Yes
No (I)
Have you gotten into trouble because you used drugs or alcohol at school?
(Required)
Yes (A)
No
Have your friends gotten bored at parties when there is no alcohol served?
(Required)
Yes (E)
No
Has it been hard for you to ask for help from others?
(Required)
Yes (H)
No
Have your parents or guardians argued a lot?
(Required)
Yes (D)
No
Has there been adult supervision at the parties you have gone to in the past 6 months?
(Required)
Yes
No (I)
Have you thought about how your actions will affect others?
(Required)
Yes
No (H)
Have you either lost or gained more than 10 pounds?
(Required)
Yes (B)
No
Were you intimate with someone who shot up drugs?
(Required)
Yes (B)
No
Have you often felt tired?
(Required)
Yes (C)
No
Have you had trouble with stomach pain or nausea?
(Required)
Yes (B)
No
Have you gotten easily frightened?
(Required)
Yes (C)
No
Have any of your best friends dated regularly?
(Required)
Yes (I)
No
Have you dated regularly?
(Required)
Yes
No (I)
Have you had less energy than you think you should?
(Required)
Yes (B)
No
Are most of your friends older than you are?
(Required)
Yes (H)
No
Have you gotten frustrated easily?
(Required)
Yes (C)
No
Have you felt alone most of the time?
(Required)
No
Yes (C,E)
Have you slept either too much or too little?
(Required)
Yes
No
Have your parents or guardians approved of your friends?
(Required)
Yes
No (E)
Have your parents or guardians refused to talk with you when they are mad at you?
(Required)
Yes (D)
No
Have you rushed into things without thinking about what could happen?
(Required)
Yes (C,H)
No
Has your free time been spent just hanging out with friends?
(Required)
Yes (I)
No
Have you accidentally hurt yourself or someone else while high on alcohol or drugs?
(Required)
Yes (A)
No
Have you had any accidents or injuries that still bother you?
(Required)
Yes (A)
No
Have you had friends who damage or destroyed things on purpose?
(Required)
Yes (E)
No
Have the whites of your eyes turned yellow?
(Required)
Yes (B)
No
Did your parents or guardians know where you were and what you were doing?
(Required)
Yes
No (D)
Did you miss out on activities because you spent too much money on drugs or alcohol?
(Required)
Yes (A)
No
Have people picked on you because of the way you look?
(Required)
Yes (B)
No
Have you felt nervous most of the time?
(Required)
Yes (C)
No
Were you told you are hyperactive?
(Required)
Yes (C)
No
Have you felt you are addicted to alcohol or drugs?
(Required)
Yes (A)
No
Have you found a hobby you are really interested in?
(Required)
Yes
No (I)
Did you feel people were against you?
(Required)
Yes (C)
No
Did you participate in team sports which have regular practices?
(Required)
Yes
No (I)
Have your friends brought drugs to parties?
(Required)
Yes (E)
No
Have your parents or guardians paid attention when you talked with them?
(Required)
Yes
No (D)
Did you use more and more drugs or alcohol to get the effect you want?
(Required)
Yes (A)
No
Have your parents or guardians made rules about what you can and cannot do?
(Required)
Yes
No (D)
Have any of your best friends gone out on school nights without permission from their parents or guardians?
(Required)
Yes (I)
No
Did you have trouble getting your mind off things?
(Required)
Yes (C)
No
Have you left a party because there was no alcohol or drugs?
(Required)
Yes (A)
No
Have your parents or guardians known what you were really thinking or feeling?
(Required)
Yes
No (D)
Did you miss school or arrive late for school because of your alcohol or drug use?
(Required)
Yes (A)
No
Did your family or friends tell you that you should cut down on your drinking or drug use?
(Required)
Yes (A)
No
Have you had serious arguments with friends or family members because of your drinking or drug use?
(Required)
Yes (A)
No
Did you have trouble sleeping?
(Required)
Yes (C)
No
Has your alcohol or drug use made you do something you would not normally do – like break rules, miss curfew or break the law?
(Required)
Yes (A)
No
Have you had trouble getting along with any of your friends because of your alcohol or drug use?
(Required)
Yes (A)
No
Have you felt that you lose control and got into fights?
(Required)
Yes (C)
No
Have you had a hard time following directions?
(Required)
Yes (C)
No
Do you have friends who have hit or threatened to hit someone without any real reason?
(Required)
Yes (E)
No
Have you been good at talking your way out of trouble?
(Required)
Yes
No (H)
Have you felt you couldn't control your alcohol or drug use?
(Required)
Yes
No (A)
Do your parents or guardians have a pretty good idea of your interests?
(Required)
Yes
No (D)
Have your parents or guardians agreed about how to handle you?
(Required)
Yes
No (D)
Have your friends cut school a lot?
(Required)
Yes (E)
No
Have you worried a lot?
(Required)
Yes (C)
No
Have you been able to make friends easily in a new group?
(Required)
Yes
No (H)
Have you been afraid to be around people
(Required)
Yes (C)
No
Do you have friends who have stolen things?
(Required)
Yes (E)
No
Have you thought it's a bad idea to trust other people?
(Required)
Yes
No (I)
Have you enjoyed doing things with people your own age?
(Required)
Yes
No (H)
Have you gone out for fun on school nights without your parents' or guardians' permission?
(Required)
Yes (I)
No
On a typical day, have you watched more than two hours of TV?
(Required)
Yes (I)
No
Have you been restless and can't sit still?
(Required)
Yes (C)
No
Have you had sexual intercourse without using a condom?
(Required)
Yes (B)
No
Signature:
(Required)