Personal Values Feedback Questionnaire

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01732 808 626 info@thinkcbt.com

Book An Appointment

Therapist Search

01732 808 626 info@thinkcbt.com

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.

Family Member
Friend
Associate
Work colleague
Anonymous

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.

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

3.10. Cooperative: operates collaboratively and harmoniously with others.

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

3.12. Creative: imaginative, resourceful and innovative.

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

3.16. Equality: treats others fairly and as equals.

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

3.17. Fairness: just, rational and reasonable.

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

3.20. Friendliness: friendly and companionable towards others.

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

3.40. Insert personal value here:(specify other)

Consistently Applies
Usually Applies
Often Applies
Rarely Applies
Not Relevant

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