Panic To Powerful Survey 1

Thank you for participating in our 12-week program! Your information will help us monitor ways in which this program might be helpful or might need refinement. Please answer each question to the best of your ability. These questions are derived from several standardized instruments used in the field of psychology. Your answers will be kept CONFIDENTIAL and your name seen only by the program administrator. All others viewing this will see the data only, not your name.

By checking the box below, you agree to share your information with the UCSF program administrator for the general purpose of program evaluation and reporting. Your information will not be used for personal assessment or psychological evaluation of any kind.

I Agree

Personal Value #1: Family Relationships
Instructions: If this is an area of your life that is very important to you, think about the type of brother/sister, son/daughter, and/or parent you want to be (do not include Couples/Romantic Relationships). Describe the most important qualities you want to have in these relationships. For example, “being supportive”, or “being an honest daughter/son”.

Please write down what you value in your Family Relationships:

Please answer the following questions by checking the number (on the right) this is true for you:

	1. Not at all important	2. A little bit important	3. Moderately important	4. Quite Important	5. Extremely Important
How important is this value to you?

	1. Not at all committed	2. Slightly committed	3. Moderately committed	4. Quite committed	5. Extremely committed
2. How committed are you to living this value?

	1. Not at all	2. A little bit	3. Moderately so	4. Quite a bit	5. Extremely so
3. Right now, would you like to improve your progress on this value?

	1. 0-20% Successful	2. 21-40% Successful	3. 41-60% Successful	4. 61-80% Successful	5. 81-100% Successful
4. In the last 10 weeks, I have been this successful in living this value:

5. I value this because:

Personal Value #2: Friendships/Social Relationships
Instructions: If this is an area of your life that is very important to you, think about the type of brother/sister, son/daughter, and/or parent you want to be (do not include Couples/Romantic Relationships). Describe the most important qualities you want to have in these relationships. For example, “being supportive”, or “being an honest daughter/son”.

2. How committed are you to living this value?

1. Not at all committed

2. Slightly committed

3. Moderately committed

4. Quite committed

5. Extremely committed