Self-Esteem and Satisfaction Survey Form
Please complete this Self-Esteem and Satisfaction Survey Form to help us understand your current feelings and experiences. All responses are anonymous and there are no right or wrong answers.
Overall, how satisfied are you with your life right now?
*
Not satisfied at all
1
2
3
4
5
6
7
8
9
Extremely satisfied
10
1 is Not satisfied at all, 10 is Extremely satisfied
How often do you feel confident in your abilities?
*
Always
Often
Sometimes
Rarely
Never
Please indicate how much you agree with the following statements.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel that I have a number of good qualities.
1
2
3
4
5
I am able to do things as well as most people.
6
7
8
9
10
I take a positive attitude toward myself.
11
12
13
14
15
How valued do you feel by others in your life?
*
Not valued at all
1
2
3
4
5
6
Highly valued
7
1 is Not valued at all, 7 is Highly valued
How often do you feel proud of your achievements?
*
Always
Often
Sometimes
Rarely
Never
On a scale of 1 to 5, how comfortable are you expressing your opinions?
*
1
2
3
4
5
How satisfied are you with your personal relationships?
*
Not satisfied
1
2
3
4
Very satisfied
5
1 is Not satisfied, 5 is Very satisfied
How often do you feel anxious about what others think of you?
*
Very often
Often
Sometimes
Rarely
Never
How much do you agree: I am satisfied with myself.
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Is there anything else you would like to share about your self-esteem or satisfaction?
Submit Survey
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