1. “A simple program of educating teens to help themselves and others before a crisis develops” Mailing address: United Teen Connection, Inc. c/o South Central Behavioral Health Network Inc., 205 Whitney Avenue, New Haven, Ct 06513 United Teen Connection, Inc. 203-789-8336 TEEN TO TEEN HELPLINE S U R V E Y AGE: 10__ 11__ 12__13__ 14__ 15 __ 16 __ 17 __ 18__ 19 __ 20 __ 22__ Other __ GRADE 6 TH __ 7 TH __ 8 TH __ 9 TH __ 10 TH __ 11 TH __ 12 __ COLLEGE: ___________ NAME OF SCHOOL _______________ NAME OF YOUTH GROUP _____________ BEST SUBJECT __________________ WORST SUBECT ____________________ 1.Did you ever hear about United Teen Connection – Primary Prevention Teen to Teen YES __ NO __ If YES where did you hear about the program? Friend __ Parent __ School __ Bus __ Radio __ Public Access TV __ Internet __ Teen Life conference __ Youth Health Fair __ Community Program ___OTHER____________________________________ 2.When you are facing a problem or need support, where do you go for support/help/understanding? Friend __ Parent/Guardian __ School teacher __ School Nurse __ Neighbor __ Church __ School Guidance Counselor __ Other ________________________________________________________ 3.Do you think that there is a need for a service such as Teens Helping Teens TEEN HELPLINE and Training? YES __ NO __ If no why is there not a need _____________________________________ 4. Would you consider calling “Teen to Teen Helpline 203-789-8336” if you needed someone to talk to? (confidentially, anonymously and with no caller ID or use of *69) YES __ NO __ PLEASE TURN PAGE OVER AND COMPLETE QUESTIONS (THANK YOU)

2. 5.During what hours do you think it is important for the TEEN TO TEEN HELPLINE 203-789-8336 be open? 3:00pm-6:00pm __ 3:00pm-8:00pm __ 6:00pm-8:00pm __ 5:00pm-8:00pm __Other _______________ 6.What kinds of problems or concerns would make you or a friend reach out for information/help/support? Academics __ boyfriend/girlfriend relationships __ birth control __ health __ Loss of a friend/relative __ Physical abuse __ loneliness __ Legal issues __ job issues __ sexual abuse __ dating violence __ sexual identity __ depression __ Hurting yourself __ Hurting others__ Running Away __ family concerns __ Hurting others __ OTHER ____________________________________________________________ 7.Have you ever called 203-789-8336? YES __ NO __ IF YES was services excellent __ good__ average__ below average __ poor __ OTHER ____________________________________ 8.Would you tell a friend who needs someone to talk to about our 203-789-8336 teen helpline? YES __ NO __ Why?________________________________________________________________ 9.Would you like to receive school Community Service Volunteer Credit Hours for participating in Training/ Answering Phone? YES __ NO__ 10.Would you use out teen to teen services or tell a friend about us? YES__ NO__ 11.In what capacity would you use our services? As a TEEN Calling in YES__ NO __ As a TEEN in Training for helpline YES__ NO __ BOTH (Teen in Training and Caller) YES__ NO__ 12.Would you like more information? YES __ NO__ If YES how can we get in contact PLEASE PRINT Phone: ________________________ email _______________________ School counselor ________________ Name: _________________________ Address _____________________ Other __________________________ 13.Do you think this PROGRAM is worth funding? YES__ NO__ WHY?______________________________________________________________ THANK YOU FOR ANSWERING THIS SURVEY Please call us if you need further information on services offered 203-789-8336 http://groups.yahoo.com/group/unitedteenconnectionnhcthttp://groups.yahoo.com/group/unitedteenconnectionnhct or united.teen.connection.n.h.ct@juno.com united.teen.connection.n.h.ct@juno.com SH 1Survey 6-16-2009