Self-Esteem and Belonging Survey
Help us understand your experiences and feelings regarding self-worth and belonging. Your responses are confidential and will be used for research and improvement purposes.
Your Full Name
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
How would you rate your overall self-esteem?
*
1
2
3
4
5
How would you rate your overall sense of belonging?
*
1
2
3
4
5
Please indicate how much you agree with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel that I am a person of worth, at least on an equal basis with others.
1
2
3
4
5
I feel accepted by people around me.
6
7
8
9
10
I have a positive attitude toward myself.
11
12
13
14
15
I feel like I belong in my community.
16
17
18
19
20
I feel respected by others.
21
22
23
24
25
In which environments do you feel the strongest sense of belonging? (Select all that apply)
*
Family
Friends
School/Work
Community/Neighborhood
Online Communities
Other
How often do you feel left out?
*
Please Select
Never
Rarely
Sometimes
Often
Always
How comfortable do you feel expressing your true self around others?
*
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Is there anything else you would like to share about your experiences with self-esteem or belonging?
Submit Survey
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