Personal Values Feedback Questionnaire
Please start by providing the name and email address of the individual to whom you are offering feedback. You can respond anonymously, and no data will be retained from this assessment. If you choose to include your initials and an email address, your results will be automatically sent to the email address provided. Please check that the email address has been entered correctly before submitting this form. All client information is managed on a strictly confidential basis. Please Note: Whilst every effort is made to ensure that our system is securely encrypted, email is not a completely secure means of communication. Think CBT does not accept liability for loss or theft of personal data where any individual chooses to transmit or receive information via email.
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Personal Values Feedback Questionnaire

Values provide a basis for guiding the way we act to overcome problems and achieve our goals. Use this feedback questionnaire to indicate how each of the following items applies to yourself or the individual you have agreed to provide feedback for.


Section 1 –Relationship to individual: Please indicate how you are linked to the individual to whom you are offering feedback.





Section 2 – Details of person providing feedback.

If you want the individual receiving feedback to know who you are when reviewing your feedback, please provide your name and contact details in the following box.


Section 3 – Personal Values:

Please check one of the boxes for each item, indicating how you feel the individual to whom you are offering feedback behaves:


3.1. Accepting: open to and accepting of self and other people.





3.2. Affectionate: displays and expresses love or strong feelings for others.





3.3. Aspiring: actively seeks opportunities and strives for success.





3.4. Assertive: respectfully stands up for own rights and balances own needs with the needs of others.





3.5. Authentic: Is genuine, honest and true to self.





3.6. Caring: helpful and considerate to self and others.





3.7. Challenging: stretches and continuously learns how to improve self and encourage change in others.





3.8. Compassionate: recognises and acts to alleviate suffering for self and others.





3.9. Conforming: respectful and obedient of helpful rules and obligations.





3.10. Cooperative: operates collaboratively and harmoniously with others.





3.11. Courageous: brave and persistent in the face of fear, threat or difficulty.





3.12. Creative: imaginative, resourceful and innovative.





3.13. Curious: open-minded, exploratory and interested.





3.14. Encouraging: promotes and rewards behaviour valued in self and others.





3.15. Emotionally aware: to be open to and receptive to my own feelings and the feelings of others.





3.16. Equality: treats others fairly and as equals.





3.17. Fairness: just, rational and reasonable.





3.18. Fitness: maintains or improves own physical, psychological and emotional wellbeing.





3.19. Flexible: adjusts and adapts readily to changing circumstances.





3.20. Friendliness: friendly and companionable towards others.





3.21. Forgiving: comes to terms with or lets go of negative feelings towards self and others.





3.22. Generosity: shares and gives freely to self and others.





3.23. Gratitude: appreciative and valuing of the things in one’s life.





3.24. Honesty: truthful and sincere with self and others.





3.25. Humour: seeks and engages in the humorous side of life.





3.26. Humility: modest about own contributions, allowing achievements to speak for themselves.





3.27. Industrious: hard-working and productive with time and resources.





3.28. Independent: self-directive and able to support self.





3.29. Orderly: properly prepared and organized in one’s life.





3.30. Open-minded: approaches issues from a receptive and objective perspective, taking time to consider other points of view.





3.31. Patient: waits calmly for what is wanted or needed.





3.32. Respectful: polite, considerate and shows positive regard to others.





3.33. Responsible: takes responsibility and ownership of own actions.





3.34. Safe: acts in a secure, protective and stable manner.





3.35. Self-aware: aware of own thoughts, feelings and actions, considerate of how one comes across to others.





3.36. Self-disciplined: acts according to goals and values, rather than vulnerabilities or weaknesses.





3.37. Tenacious: persists despite problems and difficulties and without giving up.





3.38. Tolerant: comes to terms with, acknowledges and respects things that clash with own opinions.





3.39. Trusted: discrete, loyal, faithful, sincere and reliable.





3.40. Insert personal value here:(specify other)