How are you?
Your answers are shared with a 'body image coach'. If we feel you need urgent support we have a duty of care to share your form with services that will support you. Please answer honestly, how you feel, so that we understand and can support you. This is your chance to speak.
Full name:
Parent telephone number. Or school, or other.
How are you really feeling?
I'm ok
I have good days and bad days
I'd be ok if life was easier on me
I struggle some days
I wish I could stay in bed all day, everyday
I'm happy
I'm really struggling
I don't feel safe
What was the reason for your answer above:
How do you feel about your appearance:
Do you ever wish you were someone else:
What's the reason for your answer above:
Do you like yourself when you look in the mirror:
What's the reason for your answer above:
What would you like me to know about you. Anything at all.
Is there anything holding you back in life:
Do you feel weighed down with your thoughts:
If you said yes to that question above, what do you need to do, to feel better:
Who influences you the most:
Describe your life in one sentence:
What is your age:
What is your gender? (Male, Female, Non-binary/Third gender, Prefer not to say, Other)
Male
Female
Non-binary
Gender fluid
Other
What is your ethnicity, IE:White/Caucasian 2.Black/African American 3.Hispanic/Latino 4. Asian 5. Native American/Alaska Native 6. Native Hawaiian/Other Pacific Islander 7. Two or More Races 8. Anything we have missed?
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