For each of the areas below, rate yourself with a number, 1 – 5.  Put your number in the white boxes with red outlines for each topic.  Use the following scale:

1—I would like more information.

2—I am interested in setting a self-care goal.

3—I would like more support in meeting my goal.

4—I am working toward my goal.

5—I have achieved my goal(s) in this area; this area is one of my strengths.