Self-Care Survey - StellaPsychologist

Close

Home
Services
About Us
Contact Us

Home
Services
About Us
Contact Us

Self-Care Self-Assessment Survey

Instructions: Please read each statement carefully and select the response that best describes your experience over the past month. Choose the number that corresponds to how often each statement applies to you:

Never
Rarely (Once or twice)
Sometimes (A few times a month)
Often (Once or twice a week)
Always (Almost every day)

Name

Email

Phone

1.

I engage in regular physical activity that I enjoy.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

2.

I eat a balanced diet that nourishes my body and mind.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

3.

I regularly engage in activities that promote personal growth or learning.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

4.

I prioritize activities that help me relax and unwind.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

5.

I set and maintain boundaries to protect my time and energy.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

6.

I make time for hobbies or activities that bring me joy.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

7.

I seek support from friends, family, or a support network when needed.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

8.

I practice mindfulness or meditation to manage stress.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

9.

I prioritize getting enough sleep each night.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

10.

I take breaks during the day to rest and recharge.

1. Never

2. Rarely (Once or twice)

3. Sometimes (A few times a month)

4. Often (Once or twice a week)

5. Always (Almost every day)

None

Time’s up