Name: …………………………………………………
Date:
………………………………………………….
For each of the following areas of your life – please tick the one you feel is true at this time; you may also want to add a comment. You do not have to answer everything if you do not want to.
Your health?
Lots of problems
Some problems
OK
Going quite well
Going really well
Your feelings?
Your attitudes and behaviour?
How you see yourself?
Your friends and family
– how well do you get on with people?
Your living skills – how well do you look after yourself?
Solving problems?
D:\726838782.doc

Lots of problems
Some problems
OK
Your successes
– doing well at school or work?
Going quite well
Going really well
Your learning and work – going to school and joining in?
Your hopes for the future
– do you know what you want to do?
Who looks after you?
Your family?
Housing and money?
The area where you live?
D:\726838782.doc

Is there anything else you would like to say or tell me about? Please tick one of the boxes
No
Yes
Maybe later
If you have answered yes you can put it in this box
D:\726838782.doc