1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Name:     Date:

Instructions: We are interested in how you feel about the following statements.  Read each statement carefully.   Indicate how you feel about each statement.

Circle the “1”  if you Very Strongly Disagree

Circle the “2”  if you Strongly Disagree

Circle the “3”  if you Mildly Disagree

Circle the “4”  if you are Neutral

Circle the “5”  if you Mildly Agree

Circle the “6”  if you Strongly Agree

Circle the “7”  if you Very Strongly Agree

1. There is a special person who is around when I am in need:

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2. There is a special person with whom I can share joys and sorrows:

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3. My family really tries to help me:

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4. I get the emotional help & support I need from my family:

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5. I have a special person who is a real source of comfort to me:

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6. My friends really try to help me:

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7. I can count on my friends when things go wrong:

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8. I can talk about my problems with my family:

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9. I have friends with whom I can share my joys and sorrows:

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10. There is a special person in my life who cares about my feelings:

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11. My family is willing to help me make decisions:

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12. I can talk about my problems with my friends:

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