Rate the following areas according to how well you think you are doing…
3 = I do this well (e.g., frequently)
2 = I do this OK (e.g., occasionally)
1 = I barely or rarely do this
0 = I never do this
= This never occurred to me
Physical Self-Care
_ Eat regularly (breakfast, lunch, and dinner) Exercise
_ Get regular medical care for prevention Eat healthily
_ Get medical care when needed Receive/Give physical affection
_ Take time off when sick Move mindfully
_ Yoga, Stretch, Tai Chi, Dance Get enough sleep
_ Do some fun physical activity Get fresh air/get outside regularly
_ Think positive thoughts about my body _ (Other) ______
Psychological Self-Care
_ Take breaks from the news and social media Make time for self-reflection
_ Have my own personal psychotherapy Make space for downtime
_ Take technology breaks Attend to minimizing life stress
_ Read something unrelated to school/work Be curious
_ Notice my thoughts, beliefs, attitudes, feelings Say no to extra responsibilities
_ Engage my intelligence in a new way or area Work toward life balance
_ Try new things _ (Other) _______
Emotional Self-Care
_ Spend time with people who affirm my whole self Love myself
_ Stay in contact with important people in my life Allow myself to cry
_ Re-read favorite books, re-view favorite movies Give myself affirmation/praise
_ Identify and seek out safe activities/places Find things that make me laugh
_ Practice receiving care from others unapologetically Share your feelings without shame
_ Express myself creatively (art/music/writing) Listen to/play favorite music
_ Find ways to healthily express my anger/outrage _ (Other) _______
Spiritual (or that which inspires, elicits passion/awe/perspective) Self-Care
_ Make time for reflection Spend time with elders/wise people
_ Find a spiritual or awe inspiring connection or community Be open to inspiration
_ Be aware of non-material aspects of life Cherish my optimism and hope
_ Try at times not to be in charge or the expert Invite new/bigger perspectives
_ Identify what is meaningful to me Meditate/Practice mindfulness
_ Seek out reenergizing or nourishing experiences Find time for prayer or praise
_ Contribute to causes in which I believe Have experiences of awe
_ Read or listen to something inspirational (Other) _______
Relationship Self-Care
_ Schedule regular dates with my partner/friends Make time to be with friends
_ Call, check on, or see my relatives Ask for help when I need it
_ Share a fear or hope with someone I trust Communicate with my family
_ Stay in contact with faraway friends Make meaningful connections
_ Make time for personal correspondence Spend time with animals
_ Practice healthy boundaries Practice honesty/vulnerability
_ Show and receive care/love _ (Other) _______
School or Professional Self-Care
_ Take time to chat with classmates/coworkers Make quiet time to work
_ Engage in classes/projects you are passionate about Take a break during the day
_ Balance my load so that nothing is “way too much” Set limits with my peers/boss
_ Arrange work space to be comfortable Have a support group
_ Get regular mentoring/guidance/supervision Identify strengths/rewarding tasks
_ Negotiate/advocate for my needs (Other) _______
Overall Balance
_ Strive for balance in all areas of my life on a daily and long-term basis
Strive for balance among my family, friends, and relationships
_ Strive for balance between play and rest
Strive for balance between work/service and personal time
____ Strive for balance in looking forward and acknowledging the moment
Areas of Self-Care that are Relevant to You
_ (Other) _________
_ (Other) _________
_ (Other) __________