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Chakaura^TM Power Your Life!

To Transform, Create and Heal

with Michèle St. Amour

Youth Bridge The Gap Intake Form

What’s great about being a teen is that you are in one of the best stages of life. These are exciting times but we recognize also they can sometimes be challenging.

Now is the time to DISCOVER yourself, To explore who you are, Now is the time to uncover and deeply understand your uniqueness.

Find out how to express that uniqueness to the world in a grounded and balanced way

At Chakaura™,, we recognize the needs of the next generation as each generation is clearly different than the previous one, with its own special considerations. We also understand the role of parents and/or guardians in facing personal challenges while dealing with youth challenges. We support not only youths but the whole family unit, especially the parents since they are the leaders of the pack. When anyone within a family has a loved one being challenged by life experiences, all family members are affected so all should be involved in supporting a solution.

Here are some preliminary questions to consider so together we can explore and navigate the life challenges that present themselves for us to grow into being better people. We are here to support your Journey of Self-Discovery and these questions gives us a peek into your world which helps us better help you.

Many of our questions are about things that can affect your health and well-being. Some of the questions might not fit you. It is okay to leave some questions blank. Please answer these questions on your own, without help from an adult or friend, and be as honest as possible. Your answers are private and kept confidential.

We will only talk to your parent/guardian about this information if we have a serious concern about your health and safety.

BUT, before we talk to a parent/guardian, we will talk about it with you first.

PLEASE FIND A QUIET PLACE TO ANSWER THE QUESTIONS BELOW. THIS WILL TAKE A BIT OF TIME.

Chakaura Youth Program Questionnaire

Responses are private and confidential. Chakaura adheres to high codes of ethics and privacy and only under law or if a person was life threatened would we share private information to the proper authority.

Name(Required)

First Last

What you like to be called:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other/ Part Time Address

Your Grade(Required)

Birth Date(Required)

MM slash DD slash YYYY

Name of Your School:(Required)

Your physical gender at birth:(Required)

Male

Female

Gender You Associate With:(Required)

School Type:(Required)

Private / Public / Private-Pod / Homeschool / Online/ Other

Are your parents living together?(Required)

Yes

Sometimes

If No, which household do you spend the most time in:

What four words best describe you?(Required)

What do you want support with?(Required)

Is there anything you want us to focus on during the first session?(Required)

HEALTH INFORMATION

Please list any health concerns you wish to have support with and since when you have had these concerns.(Required)

Please indicate any treatments that you have tried previously to address your health issues (physical, mood, etc.) and how effective you found these treatments.(Required)

Are you currently seeing other professionals for these or other concerns, such as a doctor, psychologist, osteopath, reiki/energy practitioner, hypnotherapist, naturopath, etc.(Required)

Since birth, List any serious conditions, illnesses, injuries and/or hospitalizations & year:(Required)

Known Allergies (medical, environmental, foods)(Required)

Is a physician presently treating you for an ailment?(Required)

Yes

If yes, please describe treatment:

Have you ever had a burnout or do you suffer mood swings, panic attacks, depression, etc?(Required)

Yes

Maybe

Current medication, if any, and what is it treating?(Required)

Prescription include any drugs for depression or anxiety, or to sleep.

Stress Section

Please rate your levels by 0=Low and 10=High.

How Stressful is your Life?(Required)

How Stressful is your School Life?(Required)

How Stressful is your HomeLife?(Required)

Define stress areas of your life, if any:(Required)

How do you manage your stress?(Required)

How is your mood throughout the day?(Required)

Calm

Swings

Down/Depressed

High/Can't Wind Down

What is your normal energy level in a day from 6-8 am :(Required)

0=Low and 10=High

What is your normal energy level in a day from 11 am to Noon:(Required)

0=Low and 10=High

What is your normal energy level in a day from 2-4 pm:(Required)

0=Low and 10=High

What is your normal energy level in a day from 6-8 pm:(Required)

0=Low and 10=High

What is your normal energy level in a day from 9-11 pm:(Required)

0=Low and 10=High

General Well Being

Please describe any present or past health or issues related to STRESS that may still be bothering you or which created a traumatic effect (For example - Stresses at home, school, work, or life events)(Required)

Have you ever experienced overwhelming anxiety or panic? Yes, Sometimes, No - If so - frequency, when and how do you deal with this?(Required)

Do you find you are overly reactive - having outbursts of rage/anger? If so, how do you manage this?(Required)

If you are not managing this - what do you do when you react? (For example - outward expressions - yelling - throwing - kicking - punching - Or Inward expressions - Beating Yourself up - Negative self talk etc.) Please describe:(Required)

How do you manage expectations of parents/teachers/coaches/peer pressure/social media?(Required)

Do you ever feel overwhelmed? If so, how do you deal with this?(Required)

How do you feel when you experience people to be "in your space" and what do you do about it?(Required)

Have you ever had any previous guidance on how to manage stress? Yes, Sometimes, No - If yes, what were you taught (please explain) and did you experience it to be helpful?(Required)

How do you relax?(Required)

How did you hear about this program?(Required)

TREATMENTS

Vaccines –did you receive: (fill only what you know)

Did you receive your vaccines as a baby?(Required)

Yes

Don't Know The Answer

Please list the ones you know:

Flu vaccine - How many inoculations and the date(Required)

Shingles vaccine - How many inoculations and the date(Required)

mRNA vaccine (Covid-19): JOHNSON & JOHNSON - How many inoculations and the date: or N/A(Required)

mRNA vaccine (Covid-19): PFIZER - How many inoculations and the date: or N/A(Required)

mRNA vaccine (Covid-19): MODERNA - How many inoculations and the date: or N/A(Required)

mRNA vaccine (Covid-19): ASTRAZENECA - How many inoculations and the date: or N/A(Required)

mRNA vaccine (Covid-19): BOOSTERS - How many inoculations and the date: or N/A(Required)

How are you feeling since the inoculations?(Required)

Have you had any Adverse Effects? Or an increase in any of the following since? Please check those that are relevant(Required)

Chest Pains

Paralysis/Bell's Palsy

Chronic Lethargy

Fatigue

Myocarditis

Pericarditis

Shingles

Rashes

Depression

Mood Swings

Heart Attacks

Stroke

Skin Sensitivity

Irritations

Unusual Fears/Thoughts

Circulation Problems

Joint Pain

Arthritis

Chronic Inflammation

Unfocussed

Blood Clots

Digestion/Gastrointestinal Issues

Shortness in Breath

Unusual Menstural Cycle

Headaches/Migraines

Low Energy Levels

Lung Issues/Pneumonia

Dizziness

Getting Sick Often

Nervousness / Anxiety

Loss of Drive or Interest in Things

Other? Please specify:

Morning Routine

When you get up in the morning, do you feel:(Required)

Rested Ready to Go

Takes Time To Get Around and Ready

Tired or Groggy Most The Morning

Describe your morning routine immediately after you wake up: The first hour(Required)

NUTRITION

Describe what you eat on a daily basis: (Breakfast/Time:)(Required)

Describe what you eat on a daily basis: (Lunch/Time:)(Required)

Describe what you eat on a daily basis: (Supper/Time:)(Required)

Describe what you eat on a daily basis: (Snacks/Time:)(Required)

Who is responsible for shopping and making the meals?(Required)

Do you ever throw up on purpose to lose weight or to control your weight?(Required)

Yes

Sometimes

Do you ever skip meals to control your weight?(Required)

Yes

Sometimes

Do you ever use laxativies or diet pills?(Required)

Yes

Sometimes

Energy drinks or Sports Drinks?(Required)

Yes

Sometimes

If yes, how many daily? weekly? What Brand?(Required)

SLEEP

What time do you get you in the morning?(Required)

Hours

Minutes

AM/PM

What time do you go to bed at night on average?(Required)

Hours

Minutes

AM/PM

How do you sleep at night?(Required)

Good

Fair

Poorly

When falling asleep:(Required)

Radidly within minutes

Takes a long time to fall asleep

If it takes you a long time to fall asleep: how long does it typically take, and do you know why?(Required)

Do you wake up in the middle of the night?(Required)

Yes, Sometimes or No - and if so how many times?

Do you have bad dreams or nightmares?(Required)

Yes

Sometimes

Describe your evening routine starting 1 hour till you go to bed:(Required)

ACTIVITES

General evening activities are from what time to what time approximately in hours? Example: 8pm to 11pm(Required)

Which activities do you do at night on a regular basis?(Required)

Computer / Gaming

Phone

Homework

Sports

Playing Musical Instruments

One-On-One Live Talking Socializing

Hobbies

Other

How many hours per activity in general: IE; Homework (2hrs)(Required)

How much time in hours in total on average do you spend a day on your devices (includes total computer, phone, television and gaming time)?(Required)

Less than 1 hour

1 to 3 hours

3 to 5 hours

5+ hours a day

Which type of electronic device do you spend the most time on and how many hours a day on average? IE Phone (3 hours)(Required)

How many of hours are spent on Social Media and which Platforms?(Required)

How many of hours are spent on Gaming and which Platforms?(Required)

How many of hours are spent taking to friends?(Required)

Do you get 60 minutes of physical activity per day, most days of the week? Doing what and when?(Required)

How much time a day do you spend outdoors?(Required)

Less Than 1 Hour

1 to 2 hours

2 to 3 hours

3 hours or more

What type of outdoor activities do you practice on a weekly basis?(Required)

Do you have any current or recurring physical injuries or are you physically challenged or disabled? If Yes, please describe:(Required)

Do you play sports?(Required)

Yes

Sometimes

If Yes, what type of sport and how often during the week? Describe practice, games etc.

Are your grades worse than they used to be?(Required)

Yes

Sometimes

Have you missed more than 3 consecutive days of school in the last year?(Required)

Never

Once A Few Times

Often

The main reason you have missed if you more than 3 days:(Required)

Do you have a part-time job? If yes, describe type and number of hours:(Required)

LIFESTYLE & EXPERIENCES

Answer only of you are comfortable sharing. Remember, we are here to support you and the more you wish to share, the easier it will be for us to guide you and offer alternatives to coping mechanisms that may no longer work for you.

In the PAST YEAR, have you used:(Required)

Tobacco

E-Cigarettes

Vapes (JUUL, Suorin, Blu, VUSE, Logic or other)

None

If you answered Yes to using any of the products please let us know how often. IE; Never, Often, Twice Monthly, Weekly, Daily(Required)

In the PAST YEAR, how many times have you used Alcohol:(Required)

Never

Once

Twice

Monthly

Weekly

Daily

In the PAST YEAR, how many times have you used Marijuana:(Required)

Never

Once

Twice

Monthly

Weekly

Daily

Have you tried any other drugs for fun, curiosity or coping, such as prescription pills, drugs that you sniff or huff, salvia, K2, or other illegal drugs?(Required)

Please let us know the frequency of use: Never, Once, Twice, Monthly, Weekly, Daily

Have you ever been in a gang (now or in the past)?(Required)

Yes

Sometimes Associated

Do you ever hurt or cut yourself on purpose?(Required)

Yes

Sometimes

Have you ever received a sexual message or picture?e?(Required)

Yes

Sometimes

Have you ever texted/sent a sexual message or picture?(Required)

Yes

Sometimes

Have you had any stressful or scary events that still bother you?(Required)

Yes

Sometimes

Have you ever been been bullied (in person or online)?(Required)

Yes

Sometimes

FAMILY DYNAMICS

Do you get along with your family?(Required)

Yes

Sometimes

How much time a week and when do you have family time and with who doing what?(Required)

Would you enjoy more more or less family time?(Required)

Less

With Who and Why?(Required)

Do you communicate well with your Mother:(Required)

Yes

Sometimes

Do you communicate well with your Father:(Required)

Yes

Sometimes

Do you communicate well with your Siblings:(Required)

Yes

Sometimes

Do you communicate well with your Step Parent:(Required)

Yes

Sometimes

N/A

Do you communicate well with your School Teachers:(Required)

Yes

Sometimes

Do you communicate well with your Friends:(Required)

Yes

Sometimes

Do you feel safe at home?(Required)

Yes

Sometimes

Do you have at least one adult you can really talk to?(Required)

Yes

Sometimes

Do you feel safe at school?(Required)

Yes

Sometimes

Do you feel safe in your community?(Required)

Yes

Sometimes

Do you worry about money, a place to live, food or clothing?(Required)

Yes

Sometimes

Have you ever run away from home or thought of running away from home?(Required)

Yes

Sometimes

General Questions

Are you happy with the way things are going for you? Yes / Sometimes / No - If you could change one thing about your life or yourself, what would it be?(Required)

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