Getting Your Needs Met Assessment Form
.
Part A: As a Child and Adolescent
.

Need	Did you get need met? (Yes or No)	How did you get need met?
1. Survival
2. Safety
3. Touching, skin contact
4. Attention
5. Mirroring and echoing
6. Guidance
7. Listening
8. Being real
9. Participating
10. Acceptance (Others are aware of, take seriously and admire the Real you)
11. Opportunity to grieve losses and grow
12. Support
13. Loyalty and trust
14. Accomplishment (Mastery; "Power," Control" Creativity, Having a sense of completion, Making a contribution)
15. Alerting one's state of consciousness, transcending the ordinary
16. Sexuality
17. Enjoyment or fun
18. Freedom
19. Nurturing
20. Unconditional love (including connection with a Higher Power)

These are a list of health human needs. They start with the most primitive and simple, and end with the more sophisticated and complex.

Were any of these ways unhealthy or unsafe? (Describe your answers)

.
Part B: Think of Yourself Today

Need	Are you getting each need met? (Yes or No)	How?
1. Survival
2. Safety
3. Touching, skin contact
4. Attention
5. Mirroring and echoing
6. Guidance
7. Listening
8. Being real
9. Participating
10. Acceptance Others are aware of, take seriously and admire the Real you
11. Opportunity to grieve losses and grow
12. Support
13. Loyalty and trust
14. Accomplishment Mastery; "Power," "Control" Creativity Having a sense of completion Making a contribution
15. Alerting one's state of consciousness, transcending the ordinary
16. Sexuality
17. Enjoyment or fun
18. Freedom
19. Nurturing
20. Unconditional love (including connection with a Higher Power)

.
If not, how might you do so healthily and safely? (Describe your answers)
.

Adapted from the workbook, A Gift to Myself
.

Click here to
print this survey