Self-Care Questionnaire (Part 1)
5 = Frequently 4 = Occasionally 3 = Rarely 2 = Never 1 = It never occurred to me
Physical Self-Care
____ Eat regularly (breakfast, lunch and dinner) ____ Identify comforting activities, objects, people,
____ Eat healthy relationships, places and seek them out
____ Exercise ____ Allow yourself to cry
____ Get regular medical care for prevention ____ Find things that make you laugh
____ Get medical care when needed ____ Express your outrage in social action, letters,
____ Take time off when sick donations, marches, protests
____ Get massages or do self massages ____ Play with children
____ Dance, swim, walk, run, play sports, sing, or do ____ Other:
some other physical activity that is fun
____ Take time to be sexual- with yourself, with a Spiritual Self-Care
partner ____ Make time for reflection or meditation
____ Get enough sleep ____ Spend time with nature
____ Wear clothes you like ____ Find time with nature
____ Take vacation ____ Find spiritual connection or community
____ Take day trips or mini- vacations ____ Be open to inspiration
____ Make time away from telephones ____ Cherish your optimism and hope
____ Other: ____ Be aware of nonmaterial aspects of life
____ Try at times not to be in charge or the expert
Psychological Self-Care ____ Be open to not knowing
____ Make time for self-reflection ____ Identify what is meaningful to you and notice its
____ Have your own personal psychotherapy place in your life
____ Write in a journal ____ Pray
____ Read literature that is unrelated to school or ____ Have experiences of awe
work ____ Contribute to causes in which you believe
____ Do something at which you are not expert or in ____ Read inspirational literature (talks, music, etc)
charge ____ Other:
____ Talk to someone you trust about issues
____ Notice your inner experience - listen to your Academic Self-Care
thoughts, judgments, beliefs attitudes and ____ Take short breaks when you study time
feelings ____ Take time to chat with friends
____ Let others know different aspects of you ____ Make quiet time to complete tasks
____ Engage your intelligence in a new area, i.e., go to ____ Identify projects or tasks that are exciting and
an art museum, history exhibit, sports event, rewarding
auction, theatre performance ____ Set limits with friends
____ Practice receiving from others ____ Balance your studying so no one day or part of a
____ Be curious day is too much
____ Say no to extra responsibilities sometimes ____ Arrange your work space so it is comfortable
____ Other: and comforting
____ Get regular support from peers and mentors
Emotional Self-Care ____ Negotiate for your needs with your instructors
____ Spend time with others whose company you ____ Have a peer support groups
enjoy ____ Other:
____ Stay in contacts with important people in your
life Balance
____ Give yourself affirmations, praise yourself ____ Strive for balance among school, family,
____ Love yourself relationships, play and rest
____ Reread favorite books, re-view favorite movies ____ Time management
____ Stress management
Self-Care Contract (Part 2)
As an individual becomes mindful of ones mental health and overall well-being, it is important
to highlight the positive impacts of self-care practices. Throughout the semester, you will be
faced with challenges and stressors that are associated with the human experience. This
contract is aimed for you to be mindful of the potential stressors that could occur during this
semester, as well as barriers that may prevent you from practicing self-care. Also, this contract is
an opportunity to brainstorm your own healthy coping and stress management solutions.
SELF-CARE STRATEGIES: The ways I plan to take care of myself for the rest of this semester.
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
INDICATE BARRIERS: The stressors most likely to get in the way of me taking care of myself.
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
ADDRESS BARRIERS: The plan I have for preventing these stressors from getting in the way of
taking care of myself.
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
COPING: My plan for coping if I begin to feel overwhelmed or stressed
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
SUPPORT: List [2] individuals or services on or off campus who can support and help me when
Im stressed or overwhelmed.
1. ___________________________________________________________________
2. ___________________________________________________________________
CONTACT INFO: The people I can contact to help support me when I feel stressed or
overwhelmed.
Name: _______________________ Name: _______________________
Phone #: _____________________ Phone #: _____________________
Email: _______________________ Email: _______________________
CONTRACT AGREEMENT
I, ____________________, do hereby agree to focus on my health and to take better care of
myself as of _________________ [Date].
I acknowledge the importance of being mindful of my health and that is it is an on-going life
process. As it is indicated in this contract, I am committed to practicing self care and promoting
overall wellness in my life.
____________________________ ______________________________
Signature Witness
Self-Care Questionnaire: Adapted from Transforming the Pain: A Workbook on Vicarious Traumatization, Saakvitne,
Pearlman, & Staff of TSI/ CAAP (Norton, 1996)
