Cognitive Assessment of Assertiveness
Please complete this form to help us evaluate your assertiveness skills and related cognitive patterns. Your responses are confidential and will be used for assessment purposes only.
Full Name
*
First Name
Last Name
Age
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Gender
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Male
Female
Non-binary
Prefer not to say
Other
Email Address
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example@example.com
Phone Number
Please enter a valid phone number.
Assertiveness Self-Assessment
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Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am able to express my opinions even when they differ from others.
1
2
3
4
5
I can say "no" when I do not want to do something, without feeling guilty.
6
7
8
9
10
I stand up for myself in group situations.
11
12
13
14
15
I am comfortable asking for what I need.
16
17
18
19
20
I handle criticism without becoming defensive.
21
22
23
24
25
How often do you avoid conflict by staying silent, even if you disagree?
*
Never
Rarely
Sometimes
Often
Always
In situations where your rights are challenged, how likely are you to defend them?
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Not at all likely
1
2
3
4
Extremely likely
5
1 is Not at all likely, 5 is Extremely likely
When you need help, how comfortable are you in asking for it?
*
1
2
3
4
5
Please describe a recent situation where you acted assertively or wish you had been more assertive.
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