Social Poverty
 

1. Are there people in your life that love you and are close to you? (3)
a.  A lot       b. Enough   c. Not really d. No one
 

2. Do you have people in your life that support your self-esteem, likes, and accepts you for who you are? (3)
a.  A lot   b. Enough c. Not really d. No one
 

3. Do you have people in your life who keep track and accountability of your health? (3)
a.  A lot   b. Enough c. Not really d. No one
 

4. Do you have people in your life that you can call on for financial assistance or basic needs when needed? (3)
a.  A lot   b. Enough c. Not really d. No one
 

5. Do you have people in your life who know about how your feeling and care about you taking care of your emotions? (3)
a.  A lot   b. Enough c. Not really d. No one
 

6. Is there someone you can talk about your finances and strategies on meeting basic needs? (1)
a. Yes          b. No
 

7. Is there someone that you can be emotionally intimate with? (1)
a. Yes          b. No
 

8. Is there someone that you can have warm physical contact with? (1)
a. Yes          b. No

9. Is there someone you can enjoy your day with? (1)

 a. Yes         b. No
 

10. Is there someone you can talk about your thoughts with? (1)
a. Yes          b. No

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Mental Health
 

1. How do you feel about yourself? (3)
a. I’m amazing     b. I'm ok     c. I'm inadequate d. I'm horrible

 

2.  How do you feel about your strengths? (3)
a. They’re amazing        b. They’re good    c. They’re poor     d. I have no strengths

 

3. How do you feel about your weaknesses? (3)
a.  I fully accept them    b. I am working to get rid of them

c. They consume my life          d. I hate my weaknesses
 

4. How do you feel about your idiosyncrasies (unique qualities that you have, and others don’t)? (3)
a. I appreciate them       b. They are growing on me

c. I try and hide them    d. I hate my idiosyncrasies 
 

5. What type of thoughts take up MOST of your day? (3)
a. Positive ones     b. Positive and negative ones  

c. Negative ones    d. Depressing ones

 

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Spiritual Poverty
 
1. How do you feel about your future? (3)
a. Hopeful   b. Bleak      c. Excited    d. Worried
 
2. Do you have a place to pray or spiritually reflect on life? (1)
a. Yes                    b. No
 

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Emotional Poverty

 

1. How do you feel about your emotional expression? (3)
a. I express my emotions too much

b. I express my emotions often enough

c. I don't express my emotions enough

d. I don't feel my emotions
 

2. How aware are you of your emotions? (3)
a. I’m fully aware of all happy/sad emotions

b. I’m only aware of happy emotions or sad emotions

c. My emotions just bother me

d. I don’t have emotions
 

3.  What emotions do you think you EXPRESS the most? (3)
a. Happy     b. Sad.         c. Anger      d. Fear
 

4. What emotions do you think you FEEL the most? (3)
a. Happy     b. Sad.                  c. Anger      d. Fear
 

5. What ways do you express your emotions? (3)
a. Exercise b. Music/Poetry    c. Dance      d. Therapy e. Private reflection
 

6. When you reflect on your past do you: (3)
a. Find it easy and positive      b. Hard and vague

c. I don’t reflect on past           d. I can’t reflect on past

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Physical Health

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1. How often do you exercise for 30 minutes or more in a week? (3)
a. 5 times a week or more        b. 3-4 times a week        

c. 1 day a week     d. Never
 

2. How often do you stretch in a week? (3)

a. 5 times a week or more        b. 3-4 times a week        

c. 1 day a week     d. Never
 

3. How often do you eat fruits/vegetables? (3) 
a. Daily       b. 3-5 times a week

c. 1-2 times a week         d. Never
 

3. How often do you control food portion sizes?  (3)
a. Daily       b. Frequently

c. Sometimes         d. Never
 

4. How many days a week do you drink water? (3)
a. Everyday          b. A few days a week

c. A couple days a week           d. None
 

5. Rate your stress level: (3)
a. Not stressed      b. Moderate

c. High        d. Extremely High

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Financial Poverty
 

1.  Do you receive a steady income that covers you basic needs sufficiently? (1)
a. Yes b. No

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2. Do you live with people who cover your basic needs sufficiently? (1)
a. Yes b. No
 

3. If you were to lose your income or connection with people you’re staying with, would you have a back up plan? (1)
a. Yes b. No
 

4. Do you have an emergency savings fund (3 to 6 months of saving of the cost of basic needs)? (1)
a. Yes b. No
 

5.  Do you have a 5-year financial plan? (1)
a. Yes b. No