DEMOGRAPHIC PROFILE

Name: ____________________________________ Sex: 1 Male Female

Parents Educational Attainment Parent’s Monthly Income: _____________
Mother: ________________________________Number of Siblings: __________________
Father: ________________________________

INVENTORY OF PARENT AND PEER ATTACHMENT (IPPA)

By Gay Armsden and Mark Greenberg
This questionnaire asks about your relationships with important people in your life; your mother, your father, and your
close friends. Please read the directions to each part carefully.
Part I.Attachment with Mother
Some of the following statements ask about your feelings about your mother or the person who has acted as your mother.
If you have more than one person acting as your mother (e.g. a natural mother and a step-mother) answer the questions for
the one you feel has most influenced you. Please read each statement and (/) the number that tells how true the statement
is for you now.
1- Almost Never or Never True 3- Some- times True 5- Almost Always or Always True
2- Not Very Often True 4- Often True
Statements 1 2 3 4 5
1. My mother respects my feeling.
2. I feel my mother does a good job as my mother.
3. I wish I had a different mother.
4. My mother accepts me as I am.
5. I like to get my mother’s point of view on things I’m concerned about.
6. I feel it’s no use letting my feelings show around my mother.
7. My mother can tell when I’m upset about something.
8. Talking over my problems with my mother makes me feel ashamed or foolish.
9. My mother expects too much from me.
10. I get upset easily around my mother.
11. I get upset a lot more than my mother knows about.
12. When we discuss things, my mother cares about my point of view.
13. My mother trusts my judgment.
14. My mother has her own problems, so I don’t bother her with mine.
15. My mother helps me to understand myself better.
16. I tell my mother about my problems and troubles.
17. I feel angry with my mother.
18. I don’t get much attention from my mother.
19. My mother helps me to talk about my difficulties.
20. My mother understands me.
21. When I am angry about something, my mother tries to be understanding.
22. I trust my mother.
23. My mother doesn’t understand what I’m going through these days.
24. I can count on my mother when I need to get something off my chest.
25. If my mother knows something is bothering me, she asks me about it.
Part II. Attachment with Father
This part asks about your feelings about your father, or the man who has acted as your father. If you have more than one
person acting as your father (e.g. natural and step-father) answer the question for the one you feel has most influenced
you.
Statement 1 2 3 4 5
1. My father respects my feeling.
2. I feel my father does a good job as my father.
3. I wish I had a different father.
4. My father accepts me as I am.
5. I like to get my father point of view on things I’m concerned about.
6. I feel it’s no use letting my feelings show around my father.
7. My father can tell when I’m upset about something.
 8. Talking over my problems with my father makes me feel ashamed or foolish.
9. My father expects too much from me.
10. I get upset easily around my father.
11. I get upset a lot more than my father knows about.
12. When we discuss things, my father cares about my point of view.
13. My father trusts my judgements.
14. My father has his own problems, so I don’t bother him with mine.
15. My father helps me to understand myself better.
16. I tell my father about my problems and troubles.
17. I feel angry with my father.
18. I don’t get much attention from my father.
19. My father helps me to talk about my difficulties.
20. My father understand me.
21. When I am angry about something, my father tries to be understanding.
22. I trust my father.
23. My father doesn’t understand what I’m going through these days.
24. I can count on my father when I need to get something off my chest.
25. If my father knows something is bothering me, she asks me about it.
Part III. Attachment with Peers
This part asks about your feelings about your relationships with your close friends.
Statement 1 2 3 4 5
1. I like to get my friend’s point of view on things I’m concerned about.
2. My friends can tell when I’m upset about something.
3. When we discuss things, my friends care about my point of view.
4. Talking over my problems with friends makes me feel ashamed or foolish
5. I wish I had different friends.
6. My friends understand me.
7. My friends encourage me to talk about my difficulties.
8. My friends accept me as I am.
9. I feel the need to be in touch with my friends more often.
10. My friends don’t understand what I’m going through these days.
11. I feel alone or apart when I am with my friends.
12. My friends listen to what I have to say.
13. I feel my friends are good friends.
14. My friends are fairly easy to talk to.
15. When I am angry about something, my friends try to be understanding.
16. My friends help me to understand myself better.
17. My friends care about how I am feeling.
18. I feel angry with my friends.
19. I can count on my friends when I need to get something off my chest.
20. I trust my friends.
21. My friends respect my feeling.
22. I get upset a lot more than my friends know about.
23. It seems as if my friends are irritated with me for no reasons.
24. I can tell my friends about my problems and troubles.
25. If my friends know something is bothering me, they ask me about it.
THE BRIEF YOUNG ADULT ALCOHOL CONCEQUENCES QUESTIONNAIRE
Developed by Kahler, Christopher W.; Strong, David R.; and Read, Jennifer P.
Instructions: Please indicate whether the following events have occurred in the past year (yes/no).
Statement Yes No
1. While drinking, I have said or done embarrassing thing.
2. I have had a hangover(headache, sick stomach) the morning after I have been drinking.
3. I have felt very sick to my stomach or thrown up after drinking.
4. I often have ended up drinking on nights when I had planned not to drink.
5. I have taken foolish risks when I have been drinking.
6. I have passed out from drinking.
7. I have found that I needed larger amounts of alcohol to feel any effect, or that I could no longer
get high or drunk on the amount that used to get me high or drunk.
8. When drinking, I have done impulsive things I regretted later.
9. I’ve not been able to remember large stretches of time while drinking heavily.
10. I have driven a car when I knew I had too much to drink to drive safely.
11. I have not gone to work or missed classes at school because of drinking, a hangover or illness
cause by drinking.
12. My drinking has gotten me into sexual situations I late regretted.
13. I have often found it difficult to limit how much I drink.
14. I have become very rude, obnoxious or insulting after drinking.
15. I have woken up in an unexpected place after heavy drinking.
16. I have felt badly about myself because of my drinking.
17. I have had less energy or felt tired because of my drinking.
18. The quality of my work or school work has suffered because of my drinking.
19. I have spent too much time drinking.
20. I have neglected my obligations to family, work, or school because of my drinking.
21. My drinking has created problems between myself and my boyfriend/girlfriend/spouse, parents or
other near relatives.
22. I have been overweight because of drinking.
23. My physical appearance has been harmed by my drinking.
24. I have felt like I needed a drink after I’d gotten up (that is, before breakfast)

SEXUAL BEHAVIOR QUESTIONNAIRES

From Youth Risk Behavior Survey

Instructions: Please read each statement and (/) the item that tells how true the statement is for you now.

1. Have you ever had sexual intercourse?

Yes No

2. How old were you when you had sexual intercourse for the first time?

I have never had sexual intercourse 15 years old

less than 12 years old
12 years old 16 years old
13 years old 17 or more years old
14 yrs old
3. During your life with how many people have you had sexual intercourse?
I have never had sexual intercourse
1 person 4 people
2 people 5 people
3 people 6 or more people
4. During the past 3 months, with how many people did you have sexual intercourse?

I have never had sexual intercourse 4 people

I have had sexual intercourse 5 people
but not during the past 3 months
1 person 6 or more people
2 people
3 people
5. Did you drink alcohol or used drugs before you had sexual intercourse the last time?

I have never had sexual intercourse

Yes
No
6. The last time you had sexual intercourse, did you or your partner use condom?

I have never had sexual intercourse

Yes No
7. The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy? ( select
only one response.)

I have never had sexual intercourse

No method was used to prevent pregnancy
Birth control pills
Condoms
Depo-provera (or any injectable birth control)
Withdrawal
Some other method
Not sure
FREQUENCY-QUANTITY QUESTIONNAIRE
By Linda A. Dimeff
Instruction: Please read each statement and (/) the item that tells how true the statement is for you now.
1. Think of the occasion you drank the most this past month. How much did you drink?
No drinks 7-8 drinks 15-16 drinks
1-2 drinks 9-10 drinks 17-18 drinks
3-4 drinks 11-12 drinks 19 or more
5-6 drinks 13-14 drinks
2. On a given weekend evening, how much alcohol do you typically drink? Estimate for the past month?
No drinks 7-8 drinks 15-16 drinks
1-2 drinks 9-10 drinks 17-18 drinks
3-4 drinks 11-12 drinks 19 or more
5-6 drinks 13-14 drinks
3. How often in the past month did you drink alcohol?
I do not drink at all Three to four times a month
About once a month Nearly everyday
Two to three times a month Once a day or more