What is your age______? Are you Male or Female (circle one)? M F
What is your education? (circle highest) Grade: 1 2 3 4 5 6 7 8 9 10 11 12: Trade school/Associate degree – or 2years past H.S.‚ Bachelor’s Degree – or 4 years past H.S.‚ Graduate School – more than 4 years past H.S. Graduate degree
What is your race/ethnicity? ________________________________________
Where do you live? City_______________ State_________________________
DIRECTIONS: FOR EACH STATEMENT‚ PLEASE CIRCLE THE NUMBER THAT INDICATES WHAT IS MOST LIKE YOU. IF YOU FEEL IT DOES NOT APPLY TO YOU‚ CIRCLE THE 9 UNDER NOT APPLICABLE
1. I don’t think there is anything good in my life.
2. There is hope for me even when I do not feel well.
3. I manage my pain or physical difficulties
4. When I do creative things I feel better.
5. I need to believe in something to change.
6. I develop plans to take care of myself‚ e.g. eating well‚ sleeping enough‚ exercising.
7. I visit a number of places to see where I can make friends.
8. I have an active social support network.
9. I am in a great deal of pain and/or I experience physical difficulties.
10.I will find places where I can make friends.
11.I live in a safe place.
12.I find ways to improve my financial situation.
13.I am using my mind to the best of my ability.
14.I feel rage.
15.The thought that there is nothing good in my life is affecting my mental health.
16.I can find a spiritual path that works for me.
17.I am committed to respecting my body and taking care of it.
18.I participate in meaningful activities.
19.There is no meaning or purpose to my life.
20.I want my suffering to end so I can move on with my life.
21.With the help of others‚ I feel better.
22.I will ask for help from others.
23.I can plan for my own future.
24.I can get on with my life when I have hope.
25. I feel confused.
26.I want help to better my situation.
27.I will seek out activities I enjoy.
28.I won’t be disabled by hopelessness and suffering.
29.Helping others find meaning and purpose helps me feel connected and empowered.
30.I don’t take care of myself in any way.
31.I recognize I need to be active.
32.There is a basis for my pain.
33.When I have difficult feelings‚ I surround myself with positive experiences.
34.I can make my own decisions
35.I am taking care of myself on a daily basis
36.I feel isolated
37.I am learning how to manage my pain and physical difficulties.
38.I am determined to make my plans for self-care work.
39.I am homeless.
40.I live in poverty.
41.I have no one to help me.
42.I need to interact with people that nourish my wellbeing
43.I look for something better through reading and talking to people.
44.When I take care of myself I feel better
45.I am not able to work
46.I think there is something better for me.
47.I am determined to keep a positive outlook on life.
48.I will choose the people I want to be with.
49.I feel frightened a lot of the time.
50.I can maintain the housing of my choice
51.Being in distress affects my body and how I care for myself.
52.I can find a purpose for living.
53.I need to have people in my life who are supportive‚ accepting‚ and understanding.
54.Social supports can help change my situation.
55.I have financial stability.
56.I have lost friends or family members because of my illness
57.I can find my way out of homelessness and poverty.
58.I will limit my interactions with people who do not support my recovery
59.There are healthy ways to end my suffering.
60.I think I can build some friendships.
61.I look for social supports.
62.I am determined to keep my mind stimulated and open to new ideas
63.I have a regular source of income.
64.I have no desire to do any activities
65.I need to reconnect with people in my past.
66.When I do creative things with other people I have more energy
67.I follow through on my plans to care for myself.
68.I am determined to be open to meeting new people
69.I feel discriminated against by family or friends because of my mental illness.
70.having a safe and comfortable living situation helps my recovery
71.People I know make friends at churches‚ social clubs‚ drop-in centers‚ school or work so I can too
72.I focus on empowering thoughts that support my mental health
73.I am committed to caring for myself
74.I am hurting for a reason
75.I recognize I can be active
76.No one would hire me to work for them.
77.I am committed to nurture my relationships.
78.I want my feelings to change
79.I want to learn about what will be helpful for me.
80.I will seek people to be with who support my recovery.
81.I want to explore choices about possible activities
82.If social supports I need are not available I will work with others to create them.
83.I have physical well-being.
84.I am not able to do things to take care of myself‚ like cooking or laundry.
85.I want to learn more about taking care of myself.
86.I will choose people to be in my life
87.I have an active and fulfilling social life.
88.Nothing is changing in my life.
89.I feel hopeless
90.I need to make connections with people.
91.My life has meaning and value.