WES Assessment

WORTH, ESTEEM, & SIGNIFICANCE (WES) ASSESSMENT

Research Consent Form
Introduction:
You are participating in a self-assessment study exploring worth, esteem, and significance in personal and relational contexts. Your participation is voluntary, and you may withdraw at any time without penalty. Please review the following information carefully before proceeding.

1. Purpose of the Assessment
The WES Assessment helps individuals reflect on how they perceive self-worth, esteem, significance, and relational experiences. This tool is for self-reflection and insight and is not a diagnostic instrument. This report generated by your responses is intended for self-reflection and personal growth, should not be used as, or considered to be, a diagnostic tool, and should be used in conjunction with therapy, mentoring, or coaching.

2. What to Expect
You will complete a 48-question survey measuring different aspects of self-worth and relationships.
Responses will be rated on a 5-point scale (Strongly Agree to Strongly Disagree).
The assessment will take approximately 5 to 10 minutes to complete.
Upon completion, you may receive a summary of your results for self-reflection.

3. Confidentiality & Data Protection
Your responses will be kept confidential and stored securely.

No personally identifying information is required unless you choose to share it.
Data may be used for research or educational purposes, but only in aggregated and anonymized form.
Individual results will not be shared with third parties without your consent.
If you have concerns about data security, you may contact Nathan D. Croy at info@ex-ft.com.

4. Potential Risks & Benefits
Risks:
Some questions may prompt emotional reflection on self-worth or relationships.
If you feel uncomfortable, you may skip questions or exit the assessment at any time.
If you experience distress while completing this assessment and would like to seek professional support, the following resources may be helpful:

📞 Immediate Support (Crisis Hotlines)
- 988 Suicide & Crisis Lifeline (U.S.) – Call or text 988 for 24/7 support.
- Crisis Text Line (U.S. & International) – Text HOME to 741741 to connect with a trained crisis counselor.
- SAMHSA National Helpline (Substance & Mental Health Support) – Call 1-800-662-HELP (4357) for free, confidential treatment referrals.
🌍 Find a Therapist
- Psychology Today Therapist Directory: www.psychologytoday.com
- Open Path Collective (Low-Cost Therapy): www.openpathcollective.org
- Mental Health America (MHA) Resources: www.mhanational.org
🏥 Insurance & Community Mental Health

Contact your insurance provider for in-network mental health services.
Search for a Community Mental Health Center (CMHC) in your area via FindTreatment.gov.
If you are in immediate danger or need urgent help, please call 911 or go to the nearest emergency room.

Benefits:
Increased self-awareness of personal strengths and growth areas.
A structured framework for reflecting on self-worth and relationships.
Opportunity to identify patterns and make intentional changes.

5. Voluntary Participation & Right to Withdraw
You are not required to participate.
You may stop the assessment at any time without penalty.
If you withdraw, your responses will not be saved or analyzed.

6. Contact Information
If you have questions, concerns, or wish to withdraw your data, please contact:

Nathan D. Croy
Licensed Clinical Marriage & Family Therapist (LCMFT)
Member, American Association for Marriage and Family Therapy (AAMFT)
Info@ex-ft.com 888.631.3938

For concerns about research ethics, you may contact AAMFT Ethics Committee at ethics@aamft.org.
Consent to Participate*

I have read and agree to the informed consent and the collection of my data.
Are you currently enrolled in FLUX, our intensive outpatient psychotherapy program?*

YesNo
Are you completing this assessment as your intake or upon completion of FLUX?

IntakeDischarge

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
1. I believe I am inherently valuable, regardless of my achievements:
2. My worth as a person is dependent on external factors like success or appearance:
3. I feel a deep sense of self-acceptance, even with my flaws:
4. I often criticize myself harshly and feel I am never good enough:
5. I believe I deserve happiness and fulfillment in my life:
6. I struggle to accept compliments or positive feedback:
7. I treat myself with kindness and compassion, even when I make mistakes:
8. I frequently worry about whether I am a "good" person:

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
9. I am generally confident in my abilities and skills:
10. I often compare myself negatively to others and feel inadequate:
11. I feel comfortable expressing my opinions and needs:
12. I tend to downplay my accomplishments and focus on my shortcomings:
13. I believe I am capable of achieving my goals:
14. I am afraid of failing or making mistakes:
15. I am comfortable receiving praise and recognition for my achievements:
16. I often feel self-conscious or worried about what others think of me:

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
17. I feel that my life has a purpose or meaning:
18. I believe I make a positive impact on the world or the lives of others:
19. I often question the meaning of life and my place in it:
20. I feel like my life is valuable and contributes to something larger than myself:
21. I feel a strong connection to something beyond myself (e.g., nature, spirituality, humanity):
22. I often feel lost or directionless, unsure of what I want to do with my life:
23. I believe my actions and choices matter and have an impact:
24. I sometimes feel like my existence is insignificant or meaningless:

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
25. I believe I deserve to be loved and respected in my relationships:
26. I often feel like I have to earn love and acceptance from others:
27. I believe I am worthy of healthy and fulfilling relationships:
28. I frequently worry that I am not good enough for my partners or loved ones:
29. I believe I am capable of giving and receiving love in a healthy way:
30. I fear that I will be rejected or abandoned by the people I care about:
31. I believe that I am inherently deserving of connection and belonging:
32. I often feel like a burden to others in my relationships:

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
33. I feel confident in my ability to build and maintain healthy relationships:
34. I often feel anxious or insecure in my relationships, worrying about what others think of me:
35. I am comfortable expressing my needs and boundaries in my relationships:
36. I tend to avoid getting too close to people or avoid emotional intimacy:
37. I believe I am capable of navigating conflict and disagreements in a healthy way:
38. I often feel misunderstood or unheard in my relationships:
39. I am comfortable being vulnerable and sharing my true self with others:
40. I often worry about being judged or criticized by my partners or loved ones:

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
41. My relationships enrich my life and contribute positively to my sense of purpose:
42. I often question whether my relationships truly contribute meaningfully to my life:
43. I prefer deeper relationships despite their challenges over superficial or casual connections::
44. I tend to avoid deeper connections because I fear being emotionally overwhelmed or rejected:
45. I actively nurture my relationships because they add meaning and fulfillment to life:
46. I find deeper relationships emotionally risky, so I keep interactions casual or superficial:
47. I worry that relationships distract me from personal growth or self-fulfillment:
48. I genuinely believe my relationships enhance my well-being and personal meaning:

WORTH, ESTEEM, & SIGNIFICANCE (WES) ASSESSMENT

WES Assessment

Instructions