Self Assessment Questionnaire

A self assessment questionnaire is a document which carries questions that forces an individual to introspect on his behavior, performance, attitude to life, social interactions and so on. In other words, a self assessment questionnaire makes one look inward to discover the causes of his actions and determine whether changes are to be made. It is an exercise in self awareness, and must be conducted seriously.

Sample Self Assessment Questionnaire:

Name: Louise Bennett

Age: 18

Date of self assessment: 23rd June 2012

Self assessment conducted by: Help for Depression, an NGO, working for the identification of depression and allied disorders among school children.

Please answer the following questions carefully.

  1. How often do you feel depressed or have mood swings?
  • Very often.
  • Occasionally.
  • Rarely.
  • Yes, I have received sustained counseling for my mood swings.
  • No, I have not received long term treatment yet.
  • I have been occasionally counseled by friends and family.
  • Yes, I have been harmed professionally by my inability to maintain consistency of temperament.
  • No, so far I have not been impacted by my depression.
  • I am not sure.
  • I feel it is time I opt for counseling.
  • No, I do not think it is time for medical opinion yet.
  • I am not sure.
  1. Have you ever been counseled for these depressive tendencies, or received benefit of an expert practitioner in psychology or counseling?
  1. Has your depressive tendencies and general social awkwardness impacted your ability to function at your workplace or seriously damaged relationships with close members of your group yet?
  1. Are you willing to go in for comprehensive treatment at this point?


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