Assessment Instructions:

Complete the following assessment. Each question can be answered with a Yes or No response. Scoring instructions will be provided in the next section.

 

Section One: Belief in Personal Abilities (13 Questions)

1. Do you believe you are capable of accomplishing your goals?

2. Do you believe you have healthy and realistic aspirations and goals?

3. Are you able to see your accomplishments without an expectation of perfection?

4. Are you able to separate your value and worth from your productivity?

5. Are you able to relinquish control?

6. Do you know how to navigate situations, even when things are going well?

7. Are you able to soothe yourself when you make mistakes or feel embarrassed?

8. Are you able to see and acknowledge your value and worth, even if others do not?

9. Do you have a healthy sense of self-esteem?

10. Would you describe yourself as special?

11. Can you list your unique talents and abilities?

12. Are you able to sit with your feelings and emotions?

13. Are you working towards filling any major voids in your life?

 

Section Two: Relationship with Food and Body (9 Questions) 

1. Do you use food as a distraction or a way to soothe yourself?

2. Do you use food to fill voids in your life?

3. Do you connect your weight, size or the amount of food you consume to your sense of success?

4. Do you feel the need to explain or justify the amount of food you eat?

5. Do you ever feel uncomfortable eating with others?

   1. If they eat less than you?

   2. If they are in smaller bodies than you?

   3. If they are consuming less calories than you?

6. If/when you are in a group, if everyone decides to make “healthy” food selections, does that influence what you order?

7. Do you restrict or limit specific groups of foods for reasons other than allergies?

8. Do you have a strong desire to lose weight or make modifications to your physical appearance?

9. Do you fear gaining weight?

 

Section Three: Relationships with others

1. Do you have at least one person you consider to be a true friend?

2. If you are in a romantic relationship, would you feel comfortable describing it as “healthy”? 

3. Do you have healthy boundaries in your personal and professional relationships?

4. Are you able to trust others with your true self?

5. Do you feel the need to mask or code-switch when in foreign environments?

6. Do you measure your sense of success based on how you compare to others?

7. Can you say with confidence that you are honest with others?

8. Do you find yourself “bending the truth” for others?

 

Section Four: Emotional Maintenance and Ability to Cope/Self-Soothe

1. When you are disappointed or hurt, are you able to bounce back without focusing on food or your body?

2. Are you fully aware of your triggers? 

3. Do you have an effective (tried and tested) plan to move past triggering moments, without using behaviors?

4. Do you reflect on triggered moments, do you carry a sense of shame or guilt?

5. Are you currently in therapy or in the care of a mental health professional?