Instructions: This questionnaire is about the support and assistance people may receive from others. Put a check to show how sure you are that you receive the kind of support described in each item.

For the correct answers, click here. __________________________________________________________________________________ _

Definitely Yes = 5; Probably Yes = 4; Maybe = 3; Probably No = 2; Definitely No = 1

Definitely Yes   Probably Yes    Maybe    Probably No   Definitely No                                                                                                     

                                                                                   1. Are there people you trust to give you advice?

                                                                                  2.  Are there people you feel comfortable contacting                                                                                                              you if you are lonely?

                                                                                   3. Are there people who would go out of their way                                                                                                                 to give you a ride if you needed one?

                                                                                  4. Are there people  who would look after your home                                                                                                               if you had to go away for awhile?

                                                                                  5. Are there people who are willing to criticize you for for                                                                                                         your own good?

                                                                                  6. Are there people  who are proud of your your                                                                                                      accomplishments?

                                                                                  7. Are there people  who would help you move to a new home?                                                                                                   home?

                                                                                  8. Are there people who would lend you money if you you                                                                                                       needed it?

                                                                                  9. Are there people with whom you share your deepest deepest                                                                                                 thoughts and feelings?

                                                                                 10. Are there people who would help you if you had too too                                                                                                         much to do?

                                                                                  11. Are there people you could stay with if you needed needed                                                                                                   to get away for awhile?

                                                                                  12. Are there people who help you feel good about about                                                                                                       yourself?

                                                                                  13. Are there people who care deeply about you?

                                                                                  14. Are there people you call if you want to go out on on                                                                                                           the spur of the moment?

                                                                                  15. Are there people who would run errands for you if if                                                                                                             you are sick?

                                                                                  16. Are there people who accept you just the way you                                                                                                          you are?

                                                                                  17. Are there people who give you physical you                                                                                                         affection?

                                                                                  18. Are there people who are willing to help you make you                                                                                                         important decisions?

                                                                                  19. Are there people who help you feel better when you when                                                                                                       are upset?

                                                                                  20. Are there people who help you work out personal personal                                                                                                  problems?

                                                                                  21. Are there people who are supportive of you no          matter matter                                                                                                     matter what?

_________________________________________________________________________________________________

For the correct answers, click here. 

Source: Program Evaluation Handbook: Stress Management. U.S. Centers for Disease Control and U.S. Department of Health and Human Services. (Prepared by IOX Assessment Associates, California, 1988.)