Pre-Class Survey

Student | Pre-Class Survey v1

How safe do you feel in your everyday life? (1 = not at all; 5 = 100% secure)

What is your confidence level? (1 = least confident, 5 = most confident)

How confident are you that you could say no when you want to if someone is asking you for a favor? (1-5)

How confident are you that you could say no to peer pressure? (1-5)

What is your biggest concern surrounding your personal safety?

Are there triggers (things you worry about) we should know about before we start the class?

On a scale of 1-5 (5 being the most confident) how confident are you that you could:

* Say no to someone trying to hug you when you don’t want them to?

* Walk away if someone tried to get a rise out of you?

* Stop fighting after you start before causing harm (physical or emotional)?

* Defend against an attacker?

Do you have previous background in self-defense? If so, what?

What can we help you with that will better prepare you for an adverse situation?

What is your biggest concern surrounding your safety?

Have you ever been attacked, experienced abuse?

Yes

Do you have any current injuries or are you recovering from recent injury, illness or surgery? If so, please specify.

What is your age?

Do you have additional questions for us?