Self-Care Questionnaire and Contract (1) (Accessible)

Self-Care Questionnaire (Part 1)
 5 = Frequently  4 = Occasionally  3 = Rarely  2 = Never  1 = It never occurred to me
 Physical Self-Care ____ Identify comforting activities, objects, people,

____ Eat regularly (breakfast, lunch and dinner) relationships, places and seek them out
____ Eat healthy ____ Allow yourself to cry
____ Exercise ____ Find things that make you laugh
____ Get regular medical care for prevention ____ Express your outrage in social action, letters,
____ Get medical care when needed donations, marches, protests
____ Take time off when sick ____ Play with children
____ Get massages or do self massages ____ Other:
____ Dance, swim, walk, run, play sports, sing, or do
some other physical activity that is fun  Spiritual Self-Care
____ Take time to be sexual- with yourself, with a ____ Make time for reflection or meditation
partner ____ Spend time with nature
____ Get enough sleep ____ Find time with nature
____ Wear clothes you like ____ Find spiritual connection or community
____ Take vacation ____ Be open to inspiration
____ Take day trips or mini- vacations ____ Cherish your optimism and hope
____ Make time away from telephones ____ Be aware of nonmaterial aspects of life
____ Other: ____ Try at times not to be in charge or the expert
____ Be open to not knowing
 Psychological Self-Care ____ Identify what is meaningful to you and notice its
____ Make time for self-reflection place in your life
____ Have your own personal psychotherapy ____ Pray
____ Write in a journal ____ Have experiences of awe
____ Read literature that is unrelated to school or ____ Contribute to causes in which you believe
work ____ Read inspirational literature (talks, music, etc)
____ Do something at which you are not expert or in ____ Other:
charge
____ Talk to someone you trust about issues  Academic Self-Care
____ Notice your inner experience - listen to your ____ Take short breaks when you study time
thoughts, judgments, beliefs attitudes and ____ Take time to chat with friends
feelings ____ Make quiet time to complete tasks
____ Let others know different aspects of you ____ Identify projects or tasks that are exciting and
____ Engage your intelligence in a new area, i.e., go to rewarding
an art museum, history exhibit, sports event, ____ Set limits with friends
auction, theatre performance ____ Balance your studying so no one day or part of a
____ Practice receiving from others day is “too much”
____ Be curious ____ Arrange your work space so it is comfortable
____ Say no to extra responsibilities sometimes and comforting
____ Other: ____ Get regular support from peers and mentors
____ Negotiate for your needs with your instructors
 Emotional Self-Care ____ Have a peer support groups
____ Spend time with others whose company you ____ Other:
enjoy
____ Stay in contacts with important people in your  Balance
life ____ Strive for balance among school, family,
____ Give yourself affirmations, praise yourself relationships, play and rest
____ Love yourself ____ Time management
____ Reread favorite books, re-view favorite movies ____ Stress management
Self-Care Contract (Part 2)
As an individual becomes mindful of one’s 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 I’m 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)

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Self-Care Questionnaire (Part 1)

 5 = Frequently  4 = Occasionally  3 = Rarely  2 = Never  1 = It never occurred to me

 Physical Self-Care ____ Identify comforting activities, objects, people,

 COPING: My plan for coping if I begin to feel overwhelmed or stressed

Name: _ Name: _

I, ____________________, do hereby agree to focus on my health and to take better care of

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