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Application for Chat Room
Applicant Information
Full Name
Date of Birth
Month
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July
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Novemver
December
Day
1
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Year
2011
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1991
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1982
1981
Grade Entering
Grade
12
11
10
9
8
Phone Number
Email Address
Multiple Choice
1. What would you consider to be the most enjoyable way to spend your time on a Friday evening?
Go to a party with friends
Play video games alone in your room
Curl up on the living room couch and read a book
Play a board game with your family
Attend a musical concert
2. If want to have pets, which animal or animals would you prefer?
Cat
Rabbit
Fish
Dog
Horse
None
3. What would be the most fun thing for you to do on a Saturday afternoon?
Go shopping in the city
Go for a mountain hike with your family
Visit an amusement park
Visit an art museum
Dine at a restaurant
Watch a basketball game on television Play soccer with your friend
4. If you to have to work around the house, which one of these chores would you prefer?
Clean your room
Cook dinner for your family
Wash the dishes
Take the dog for a walk
Mow the grass
Shovel snow
None of them above
5. On a weekend morning, what would you rather do?
Rise early and go for a walk
Rise early and do homework
Rise early and cook breakfast for the family Sleep until noon
Sleep
6. If you lived a half mile or 0.8 kilometers from school or work, how would you prefer to travel to and from school or work during nice weather?
Car
Bicycle
Walk
7. If you were at a party with your family, friends and strangers, what would you enjoy doing the most at this event?
Talking with your friends
Spending time with your family members
Meeting new people
Sitting at a quiet table by yourself
8. If you were sad about something, who would you confide in first?
Your own parents
Your best friend
Your brother or sister
Your parents
Guidance Counselor
No one
9. Which of these activities have you experienced before? Check all that apply.
Hiking
Rock climbing
Downhill skiing
Sleeping outdoors in a tent
Football
Baseball
Swimming
10. Which of these activities would you want to try for the first time? Check all that apply.
Sailing
Canoeing
Kayaking
Hiking
Rock climbing
Lawn mowing
Riding an ATV (All Terrain Vehicle) Roller skating
Ice skating
Downhill skiing
Cross country skiing Snowmobiling
Sleeping outdoors in a tent Snow tubing or sledding Jet skiing
Football
Baseball or softball
Short Questions
1. Have you ever lived outside of your home? Where and for how long?
2. Are you open to any race, religion or ethnic background? If not, please explain.
3. Would you be willing to talk to a counselor if you are depressed?
4. Have you ever shared your depression with others?
5. What are your favorite activities?
6. Would you be willing to join in outdoor activities?
7. Would you be willing to help others?
8. Do you have any hobbies?
9. Are you taking any prescription medications? Please explain.
10. Do you have a health condition? Please explain.
11. List four words to describe yourself.
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