Device With Some Helpful Solutions

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    How Are You Doing?
    Please take a few minutes to fill out this survey. Your answers will be kept confidential. Thank you for your participation.
    General Information
    Your Mother’s Birthday (MM/DD/YYYY)
    ______/_______/___________

    imagine us touching palms. mine are sweaty.

    What’s on your mind these days?
    __________________________________________
    __________________________________________
    __________________________________________

    Describe your relationship with your mother in three words
    ____________________,____________________,____________________









    Section I
    Rank in order of importance (1 being most important, 4 being least)
    ___ Happiness             ___ Security                ___ Freedom               ___ Individuality

    Answer again assuming you now have a wife and 2 kids
    ___ Happiness             ___ Security                ___ Freedom               ___ Individuality

    Section II (circle one)

    Do you feel that your negative thoughts in regards to others are similar to any negative feelings about yourself?
    always / often / sometimes / seldom / never

    I have confused feelings about sexuality
    always / often / sometimes / seldom / never

    I consider myself loved
    always / often / sometimes / seldom / never

    Sometimes I wish to be alone for extended periods of time, possibly forever
    always / often / sometimes / seldom / never

    When it rains, I want to take my clothes off
    always / often / sometimes / seldom / never


    Section III      (True / False)
    T/F       Sometimes I like the feeling of being licked and sometimes I do not, but usually I do
    T/F       I have peed on someone
    T/F       I have peed on someone
    T/F       I am a virgin
    T/F       I have loved someone who would never love me
    T/F       You are privileged
    T/F       Every morning when I wake up, I have a hard time getting up
    T/F       And every night I have a hard time falling asleep
    T/F       I like the smell of bleach
    T/F       I prefer being cold because I like the feeling of warmth creeping back
    T/F       You are going to be remembered for a long while
    Section IV  (Short Answer)

    You can only let one parent live, who do you save?

    Do you often feel most lonely between the hours of 7-11 pm? Alternatively please write the time period between which you feel the most alone daily.

    Please describe (in as few words as possible) the situation in which you last were close enough to feel someone’s chest rise and fall with their breath.

    Do you aspire to engage with a larger group than your immediate peers? If so please describe how large and explain why.

    Do you aspire to engage with a larger group than your immediate peers? If so please describe how large and explain why.


    Section V         Check anything you consider yourself to fear:
    ☐ terrorism
    ☐ tidal waves
    ☐ hunger
    ☐ loneliness
    ☐ neglect
    ☐ death  
    ☐ life
    ☐ heavy metal poisoning
    ☐ dentists
    ☐ bad haircuts
    ☐ dandruff
    ☐ youth
    ☐ getting old and dying
    ☐ snakes
    ☐ public bathrooms
    ☐ tornadoes
    ☐ getting pregnant
    ☐ divorce
    ☐ loss a loved one
    ☐ pubic hair
    ☐ being late
    ☐ not having enough money
    ☐ getting lost
    ☐ needles
    ☐ STD’s
    ☐ not understanding
    ☐ working alone
    ☐ the realization that life is meaningless
    ☐ ;P
    ☐ teamwork
    ☐ other races
    ☐ needles
    ☐ popular culture
    ☐ missing television shows
    ☐ hot yoga
    ☐ presidential assassination
    ☐ being pooped on by birds
    ☐ brain aneurysm
    ☐ another plague
    ☐ heart attack
    ☐ cancer
    ☐ losing your retainer
    ☐ slipping
    ☐ judgement
    ☐ shark attack
    ☐ civil war
    ☐ nuclear war
    ☐ war at all
    ☐ yourself
    ☐ the future
    ☐ commitment
    ☐ lack of commitment
    ☐ infidelity
    ☐ food poisoning
    ☐ trusting someone
    ☐ heights
    ☐ small spaces
    ☐ spiders
    ☐ marriage
    ☐ authority
    ☐ not being loved
    ☐ public embarrassment
    ☐ rejection
    ☐ dating
    ☐ friends going out without you
    ☐ scabies
    ☐ failure
    ☐ poison ivy
    ☐ organized religion
    ☐ cheating
    ☐ football
    ☐ anthrax
    ☐ physical activity
    ☐ apathy
    ☐ smiling to people that you hate
    ☐ success
    ☐ not being successful
    ☐ falling pianos
    ☐ showing your friends a youtube video
    ☐ mudslides
    ☐ sinkholes
    ☐ walking in on your parents doing it
    ☐ genitalia
    ☐ death by car exhaust
    ☐ seizure
    ☐ sickness

    Write in anything that you fear that is not listed:
    _______________________________________________________________