Read each statement carefully. Decide whether you strongly agree, somewhat agree, or disagree with each statement. Put a check under the column that best fits how you feel about each statement, There are no right or wrong answers, so don't take too much time to mark your response. Trust your first reaction. When you are finished, you and your tutor will score this together.
|1 . My life lacks purpose and direction.|
|2. I feel I'm not in control of what happens to me.|
|3. I tend to say yes when I really want to say no.|
|4. I set goals and stick to them.|
|5. Most people like me and enjoy being around me.|
|6. I have a positive outlook on life.|
|7. 1 believe I can cope with whatever happens to me.|
|8. I have trouble making up my mind.|
|9. I feel good about my appearance|
|10. I state my needs and feelings without putting others down.|
|11. It's hard for me to relax and not worry so much.|
|12. My problems seem overwhelming to me.|
|13. I tend to depend on others for my happiness.|
|14. I'm good at solving problems.|
|15. Most people respect and value my opinion.|
|16. I find it easy to say good things about myself|
|17. I believe people are basically honest.|
|18. 1 don't feel that I'm successful.|
|19. I have difficulty standing up for myself|
|20. I try to take good care of my health.|
|21. It's hard for me to express love and caring.|
|22. I'm an energetic person.|
|23. I can talk to people without feeling nervous.|
|24. I feel my life has meaning.|
|25. It's hard for me to meet new people.|
Read each statement carefully. Decide whether you strongly agree, somewhat agree, or disagree with each statement. Put a check under the column that best fits how you feel about each statement. There are no right or wrong answers, so don't take too much time to mark your response. Trust your first reaction. When you are finished, you and your tutor will score this together.
|1 . My life lacks purpose and direction.||1||2||3|
|2. 1 feel I'm not in control of what happens to me.||1||2||3|
|3. I tend to say yes when I really want to say no.||1||2||3|
|4. I set goals and stick to them.||3||2||1|
|5. Most people like me and enjoy being around me.||3||2||1|
|6. I have a positive outlook on life.||3||2||1|
|7. I believe I can cope with whatever happens to me.||3||2||1|
|8. I have trouble making up my mind.||1||2||3|
|9. I feel good about my appearance.||3||2||1|
|10. I state my needs and feelings without putting others down.||3||2||1|
|11. It's hard for me to relax and not worry so much.||1||2||3|
|12. My problems seem overwhelming to me.||1||2||3|
|13. I tend to depend on others for my happiness.||1||2||3|
|14. I'm good at solving problems.||3||2||1|
|15. Most people respect and value my opinion.||3||2||1|
|16. I find it easy to say good things about myself||3||2||1|
|17. I believe people are basically honest.||3||2||1|
|18. I don't feel that I'm successful.||1||2||3|
|19. I have difficulty standing up for myself||1||2||3|
|20. I try to take good care of my health.||3||2||1|
|21. It's hard for me to express love and caring.||1||2||3|
|22. I'm an energetic person.||3||2||1|
|23. I can talk to people without feeling nervous.||3||2||1|
|24. I feel my life has meaning.||3||2||1|
|25. It's hard for me to meet new people.||1||2||3|
1. Refer to the answer key to determine the point value of each response (for example, if the learner marked the box under "Disagree" for item # 1, then three points would be awarded).
2. Enter the total number of points earned for items 1-25. TOTAL SCORE:___
3. Compare the total score with the guidelines below. Items earning 1 point on the Survey indicate low self esteem; items earning 2 points indicate moderate self esteem; items earning 3 points indicate high self esteem.
POINTS SELF ESTEEM RECOMMENDATION . 60-75 HIGH Learner is confident and competent in daily living activities. Consider using this individual as a peer tutor. 45-59 MODERATE Learner experiences occasional problems in certain daily living activities. Identify particular situations that present difficulty and develop lesson plans using role playing and problem-solving methods. . 0-44 LOW Learner has poor self esteem and lacks confidence to succeed in daily living activities. Lessons should address each life domain using positive self-talk, visualization, and role playing exercises to raise self esteem
4. Instructions should begin with those items earning 1 point, followed by items earning 2 points. Begin by asking the learner to explain why he/she marked items earning 1 or 2 points. Look for particular situations or types of individuals that pose problems for the learner. Use the Characteristics of Self Esteem Chart to determine the self esteem building block and life domain related to each item,
Read and think about each statement below. Decide if the statement describes a situation that is a problem for you. Ask yourself where and when this problem arises. Put a check in the blank under each area - home, work, learning, or social setting - in which the problem occurs.
|1. Letting others take advantage of me|
|2. Trusting others.|
|3. Expressing how I really feel.|
|4. Feeling confident about my ability to cope.|
|5. Deciding what I believe.|
|6. Being understood by others.|
|7. Figuring out what I want to accomplish in life.|
|8. Making a good impression.|
|9. Having a positive outlook on life.|
|10. Finding support when things go wrong.|
|11. Controlling my emotions.|
|12. Being flexible.|
|13. Gaining respect and approval of others.|
|14. Relaxing and managing stress.|
|15. Establishing boundaries.|
|16. Feeling safe and secure.|
|17. Listening carefully to others.|
|18. Taking care of my mental and physical health.|
|19. Getting along with others.|
|20. Discovering my talents and strengths.|
DIRECTIONS FOR THE TUTOR:
For each life domain checked, ask the learner to give specific examples of how and when the statement poses a problem. Use this information to determine possible lessons. Refer to existing lesson (in the appropriate life domain) or design a lesson using the blank problem solving format. Incorporate positive self talk, role playing, and visualization into the lessons to strengthen self esteem.
1. Watch for the following behavior traits that indicate low self esteem.
2. Put a check mark under the appropriate column to indicate the frequency and severity of each negative behavior trait. The "comments" section after each statement can be used to record specific incidents.
3. Observe the client, if possible, for several days in various situations before marking the checklist.
4. Use this checklist as a discussion tool with the client to gather more information and suggest ways to overcome low self esteem.
|1. Client tends to avoid eye contact.
|2. Client avoids talking to people.
|3. Client has difficulty interacting with authority figures.
|4. Client is not clean, neat and appropriately dressed.
|5. Client feels alone and overwhelmed by problems.
|6. Client uses defensive body language.
|7. Client has difficulty talking about him/herself.
|8. Client has trouble making decisions.
|9. Client tends to stay by him/herself
|10. Most of the client's comments are negative.
|11. Client has difficulty expressing needs and desires.
|12. Client lacks energy.
|13. Client appears suspicious and mistrustful.
|14. Client feels unable to cope with life.
|15. Client has trouble controlling emotions.