Name: _________________________________ Teacher: ____________________________

Gender: Male Female

Ethnicity: Latino Asian African American Caucasian

1. In my class my favorite friend is: ________________________________________

2. In my class the friend who gets picked on the most is: ______________________

3. I am happy with myself most of the time.

😁 😁 😁 😁 😁
Strongly Agree Neutral Disagree Strongly
Agree Disagree

4. There are a lot of good things about me.

😁 😁 😁 😁 😁
Strongly Agree Neutral Disagree Strongly
Agree Disagree

5. I make friends easily.

😁 😁 😁 😁 😁
Strongly Agree Neutral Disagree Strongly
Agree Disagree

6. I am comfortable working in groups.

😁 😁 😁 😁 😁
Strongly Agree Neutral Disagree Strongly
Agree Disagree

7. I get scared to talk to a new friend.

😁 😁 😁 😁 😁
Strongly Agree Neutral Disagree Strongly
Agree Disagree

8. I get scared to ask for help from friends or teachers.

😁 😁 😁 😁 😁
Strongly Agree Neutral Disagree Strongly
Agree Disagree

9. I have been feeling happy in the past week.

😁 😁 😁 😁 😁
Strongly Agree Neutral Disagree Strongly
Agree Disagree

10. I have been feeling lonely in the past week.

😁 😁 😁 😁 😁
Strongly Agree Neutral Disagree Strongly
Agree Disagree