Name

First Name

Last Name

I can reflect on situations that upset me and realize why it upset me.

On a scale of 1 to 5 (1 being not so much or almost never and 5 being absolutely/ almost always)

1

2

3

4

5

I can self soothe.

1

2

3

4

5

I get extremely frustrated and can't calm down.

1

2

3

4

5

When I am upset, I become compulsive in my reactions and can't take time to reflect.

1

2

3

4

5

I have a strong sense of self.

1

2

3

4

5

I am living an authentic life.

1

2

3

4

5

I know myself and what moves me.

1

2

3

4

5

I have internal dialogues with myself that allow me to grow and transform.

1

2

3

4

5

I have compassion for myself.

1

2

3

4

5

I am true to myself.

1

2

3

4

5

I know what makes me happy.

1

2

3

4

5

I know what brings me joy.

1

2

3

4

5

I am able to enjoy myself.

1

2

3

4

5

I am in touch with my feelings.

1

2

3

4

5

I surround myself with things that I love.

1

2

3

4

5

I write down my dreams.

1

2

3

4

5

I am aware that my unconscious is affecting my behaviour.

1

2

3

4

5

My actions are often based on unconscious influences.

1

2

3

4

5

I care for myself.

1

2

3

4

5

I nurture myself.

1

2

3

4

5

I love myself.

1

2

3

4

5

I have a good relationship with my body.

1

2

3

4

5

I am in touch with my feelings.

1

2

3

4

5

I am in touch with my feelings.

1

2

3

4

5