First Name

Last Name

Date of birth

Zip code

If Under 18

Guardian Name

Guardian Email

Instructions: Read each question or statement carefully and score your honest answer between 0 and 10. Use the examples provided to help you better understand how to choose your score. If you need clarification, ask a coach or village leader for help at any time. Remember that if a score is not 0 or 10 you can scored the answer as either a 1, 2, 3, 4, 5, 6, 7, 8 or 9

1. Overall, how satisfied are you with life as a whole these days?

0= Not Satisfied at all (I do not have anything that I need) 10= Completely Satisfied (I have all that I need and more)

2. In general how happy or unhappy do you usually feel?

0= Extremely Unhappy (I do not experience happiness within myself at al any day of the week) 10= Extremely Happy (I find myself happy everyday)

3. In general, how would you rate your physical health?

0 = Poor (I do not participate in any physical activity during the day or week) 10= Excellent (I participate in physical activity and feel great in my body everyday of the week)

4. How would you rate your overall mental health?

0= Poor (I have more Negative thoughts than good thoughts during the day) 10= Excellent (I have more Good thoughts than negative thoughts during the day)

5. Overall, to what extent do you feel the things you do in your life are worthwhile?

0= Not at al Worthwhile (I do not enjoy the things I do each day because they aren't helpful at all) 10= Completely Worthwhile (I love the activities I participate in and the decisions I make each day because of the positive impact)

6. I understand my purpose in life.

0= Strongly Disagree (I do not know what my dream is in life) 10= Strongly Agree (I know exactly what I desire to do, have been created to do and dream of doing)

7. I always act to promote good in all circumstances, even in difficult & challenging situations.

0= Not True of Me (I always promote negative outcomes and decisions in situations each day) 10= Completely True of Me (I think and exercise better ways to solve and make decisions in all of my situations each day)

8. I am always able to give up some happiness now for greater happiness later.

0= Not True of Me (I do not want to give up happiness now for happiness later) 10= Completely True of Me (I am okay with experiencing less happiness for more happiness to come later)

9. I am content with my friendships

0= Strongly Disagree0 = Strongly Disagree (I do not enjoy being with the friends I have now) 10 = Strongly Agree (I enjoy being with my friends every day I am able to)

10. My Relationships are as satisfying as I would want them to be.

0 = Strongly Disagree (I do not enjoy the relationships in my home and neighborhood space) 10 = Strongly Agree (I love the relationships I have in my home and neighborhood space)

11. How often do you worry about being able to meet normal monthly living expenses?

0 = Worry All of the Time (I think about paying my parents’ bills because they may not be able to) 10 = Do Not Ever Worry (I do not think about paying any of my parent bills)

12. How often do you worry about safety, food, or housing?

0 = Worry All the Time (I worry everyday about my safety, food, and living conditions) 10 = Do Not Ever Worry (I do not worry at all about any of those areas mentioned above)