* 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