Name
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NHS number
Date of birth
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Contact number
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Group / course name
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I am easily disappointed with myself
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
There is a part of me that puts me down
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I am able to remind myself of positive things about myself
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I find it difficult to control my anger and frustration at myself
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I find it easy to forgive my self
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
There is part of me that feels I am not good enough
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I feel beaten down by my own self-critical thoughts
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I still like being me
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I have become so angry with myself that I want to hurt or injure myself
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I have a sense of disgust with my self
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I can still feel lovable and acceptable
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I stop caring about myself
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I find it easy to like myself
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I remember and dwell on my failings
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I call myself names
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I am gentle and supportive with myself
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I can't accept failures and setbacks without feeling inadequate
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I think I deserve my self-criticism
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I am able to care and look after myself
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
There is a part of me that wants to get rid of the bits I don't like
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I encourage myself for the future
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me
I do not like being me
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0 – not at all like me 1 – a little bit like me 2 – moderately like me 3 – quite a bit like me 4 – extremely like me