Guilt and Shame Assessment Questionnaire
Please answer the following questions honestly to help assess your experiences with guilt and shame. Your responses are confidential and will be used for self-reflection or research purposes.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
How often do you experience feelings of guilt?
*
1
2
3
4
5
How often do you experience feelings of shame?
*
1
2
3
4
5
Please indicate how strongly you agree or disagree with the following statements.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I often feel guilty about things I have done.
1
2
3
4
5
I feel ashamed when I make mistakes.
6
7
8
9
10
I have difficulty forgiving myself for past actions.
11
12
13
14
15
I try to hide my shortcomings from others.
16
17
18
19
20
I believe that others judge me harshly.
21
22
23
24
25
When you feel guilt, how do you usually react?
*
Apologize and try to make amends
Withdraw from others
Feel anxious or restless
Try to ignore the feeling
Other
When you feel shame, how do you usually react?
*
Avoid eye contact or social situations
Become self-critical
Seek reassurance from others
Try to distract yourself
Other
In which situations do you most commonly experience guilt or shame? (Select all that apply)
*
Interpersonal conflicts
Work or academic performance
Family relationships
Breaking personal values or rules
Other
Please describe a recent situation where you felt guilt or shame and how you handled it.
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