1. First, just a few questions about demographics. What is your age range?

2. Are you

3. Marital Status:

4. Do you have children

5. Where do you live?

6. I have one close friend who authentically accepts me. I can be myself with this person. (If you have
more than 1 close friend like this, answer this as true.)

7. I have more than one friend who is safe for me, with whom I can be myself.

8. How many deep friendships do you have?

9. My family relationships are emotionally close though they may disagree with what I think and do.

10. Please choose the degree of loneliness you feel with 1 being not lonely at all and 10 being so lonely it is the most painful experience you have had.

11. Do you also feel empty?

12. Are empty and lonely the same for you? Please explain how they are the same or different.

13. What do you see as the reason for your loneliness?

14. What do you see as the reason for your emptiness?

15. Have you found solutions to loneliness and/or emptiness?

16. Do you believe loneliness (different from beng alone) is related to unhappiness?

17. I trust myself to make good decisions in relationships.

18. I am safe for myself: I do not judge or criticize myself in a harsh way for my thoughts, feelings, and
mistakes. I show compassion to myself.

19. Social networking (Facebook, Twitter and other online communities) help ease loneliness for me.

20. Television is a companion for me.

21. Books help ease my loneliness

22. I have a place where I feel safe.

23. What safety means to me:

24. I don't feel lonely when

25. I feel most lonely when

26. I don't feel empty when

27. I feel most empty when

28. In general, I feel

29. I am lonely when I am by myself for any length of time.

30. I would rather be with someone who criticizes me than by myself.

31. My biggest fear about being by myself is

Thank you for your time and thoughtfulness. Your contributions are appreciated.

T