1. Do you depressed or upset/sad as often as____ many times a week:
   a. 0 days
   b. 1-2 day
   c. 3-4 days
   d. 5-6 days
2. On a regular basic do your friends talk about hurting themselves?
    a. Yes
    b. no
3. Do you physically hurt yourself?
   a. yes
   b. no
4. If answered "yes" to number 3, why do you hurt yourself? If "no"
   move on to question 5.
5. Do you eat to comfort/cheer yourself up?
   a. Yes
   b. No
6. Does your family have a history of mental health issues?
   a. yes- little to none.
   b. yes- mild
   c. yes- many members
   d. no- none
7. Did you grow up in a unsafe neighborhood?
   a. yes
   b. no
8. Did you feel threaten a family member growing up?
   a. yes
   c. no
9. Were you sexual abused?
   a. yes
   b. no
10. Do you starve yourself?
   a. no
   b. yes, why
11. Did you grow up in a single parent home?
   a. yes
   b. no
12. Do you believe that you have a emotional issue?
   a. yes
   b. no
13. Are you:
         a. gay
         b. straight
         c. bisexual
         d. asexual
14. Was a parent(s) an alcoholic?
   a. yes
   b. no
15. Has a family member ever commit/attempted suicide?
   a. yes, they were closely related to me (parent, sibling)
   b. yes, they were a distant relative (cousin, aunt, grandparent etc)
        c. none

Sweet poem! here's one I wrote about eyes:

A pair of eyes can show everything
And nothing in the same instant.
They flash with greed, and glint with tears
They shine with happiness and widen with fears

A pair of eyes unearths the lies
They show the truth, they reveal the pain
They flatten with grief, they narrow with distrust
They become blank when needed most.

A pair of eyes can show everything,
But only if the one seeing through them allows it.
A person can hide, behind their eyes
Forcing others this truth to seek:
A person is not always what they seem.